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Seasonal Influenza (Flu) Vaccine Consent Form

Section 1: Patient Information

Ask your pharmacist about age restriction for flu shots in a pharmacy*

Section 2: Screening Questionnaire Refer to Screening Questionnaire Action Guide for recommendatios

Are you, or have you been sick within the past 3 days? (fever greater than 39.5°C, breathing problems, or active infection

Have you had difficulty breathing, wheezing or chest tightness within 24 hours of getting an influenza vaccine?

Are you allergic to any part of the influenza vaccine, or have you had a severe, life-threatening allergic reaction to a past influenza vaccine?

Are you allergic (eg. Wheezing, chest tightness, difficulty breathing, hives) to: • Contact lens solution • Egg or egg products • Formaldehyde • Gelatin • Gentamicin • Kanamycin • Neomycin •Thimerosal•Polymyxin B

Do you have a serious allergy to latex or natural rubber?

Have you had a reaction to eggs or egg products but can still eat small amounts of egg? (eg. Stomach ache, skin reaction)

Have you had Guillian-Barré Syndrome within 6 weeks of getting an influenza vaccine? Oculo-Respiratory Syndrome?

Have you ever had a seizure or have an active, new, or changing neurological disorder?

Do you have bleeding problems or use blood thinners? (eg. Warfarin)?

Are you pregnant, nursing, or do you intend to become pregnant?

Have you received your pneumonia vaccines? If yes, which vaccine and when:

Have you received your shingles vaccines? If yes, which vaccine and when

Only fill this section if planning to receive the nasal influenza vaccination

Have you received any vaccines in the last 4 weeks?

For children under 18 years old: Is the child using, or will be using an aspirin/aspirin-containing therapy in the next 4 weeks?

Do you have severe asthma (on high dose inhaled or oral corticosteroids) or medically attended wheezing in the past 7 days?

Have you received in the past 48 hours or do you intend to receive in the next 2 weeks flu antiviral therapy? (eg. Oseltamivir)?

Do you have any medical conditions (eg. Cancer, leukemia, HIV/AIDS) or take medications that weaken the immune system?

Do you provide health care services to or do you have close contact with persons who are immunocompromised?

Are you allergic (eg. Wheezing, chest tightness, difficulty breathing, hives) to Arginine?

Section 3: Consent Given By Patient/Agent

I, the undersigned patient, parent or guardian, have read or have had explained to me information about the seasonal influenza vaccine (“Vaccine”) as outlined on the Flu Vaccine Fact Sheet. I have had the chance to ask questions, and answers were given to my satisfaction. I understand the risks and benefits of receiving the Vaccine. After getting the Vaccine, I agree to wait in the clinic/pharmacy for 15 minutes (or the time recommended by the pharmacist). I am aware it is possible (yet rare) to have an extreme allergic reaction to any component of the Vaccine. Serious reactions called “anaphylaxis” can be life- threatening medical emergencies. Symptoms of an anaphylactic reaction may include hives, difficulty breathing, swelling of the tongue, throat, and/or lips. If I experience such symptoms following vaccination, I am aware it may require the administration of epinephrine, diphenhydramine, beta-agonists, and/or antihistamines to treat this reaction and 9-1-1 will be called to provide additional assistance. In the event of anaphylaxis, I, my agent, and/or EMS paramedics will receive a copy of this form. I understand the information contained on this form, may be disclosed to the public health authority and to other required parties for the purpose of adverse event and drug safety reporting. Moreover, I understand fully that this form is being provided as an empty template, and that the information I include in this form may constitute Personal Information or Personal Health Information as under the relevant privacy legislation. I am fully aware of the risks involved in sending, submitting, or storing this form and any included Personal Information or Personal Health Information via email or other digital means. I therefore release the form creator, publisher, or any other entity involved in the production or distribution of this form from any and all liability relating to relevant privacy legislation.

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