flu vaccine consent form 2019 pdf

These symptoms clear up within a few days. ��NH'Q^�V�!�RT��;�� ���3� Wx�n\^����Ѐ� ��� wH�8��,�=`o1�X��i�����+� �J� "The Flu Vaccine - Protect yourself, Protect others" This module has been developed by the Workplace Health and Wellbeing Unit ... Anaphylaxis Protocol (Updated April 2019) Self Assessment; Please click on the links below for the Flu Medicine Protocols training materials for the 2019/2020 season. Flu Vaccine Form Patient Name: Date: F: M: DOB: Age: Phone: Address: City: State: Zip: I, the undersigned, have read or had explained to me the vaccine information sheet (VIS). h�Ė�n�8�_��-Ϥ|�[Mv{��.��uؒ!����;C,�v�]`[2��9$�_��0"D@��"$& BBK ���2� ��PJ�Y��"\Z��p��Ҁ��%�q�FkM�‰�(�� �phV M޽��kz��dG��G�����*�}H��x�&��p����e BN'߶w�z$�q:K\�}�� %����BpC�d[)�"Ϫ�4�.4�������w�${G��ޕ7��|�d��׾�\1F�U�K&�v��]�I�-Q�^'OuB�`EW����z8fU��*/��&Y���e�d�H8|��^��6 �����B�v4��Z!�1ֿ��hm��o;�Aص��Qhao=Vxշ�O�ΈV���ٵ�=�*��E�>�Ʈ���8��LJ�'y���!G�]�M�2�ꋴ(��cR�1�d�~Ln �.8]}���u��y�:��Ǭ�r�����/k.� �"��b��6Cu�q�IZu�����SJ9���5�1�>�&Zֽ>�f�P�2oa�=������ئ�ze?o�xzE4e���z�2�vhk��@.���S�kl���� ����7��Q���?��+`�7� �V�o�ۦeUvn�����E�s�/%�_�oǜE�U,��Dx��D�� �!z��D#�����Pk�����jlX]ԩ� tl���q���ͭ��! A small percentage of people may experience a mild fever and feel unwell for a few days – this is not the flu. The flu vaccine is very safe and generally people have no reaction. endstream endobj 174 0 obj <. Annual Influenza Vaccine Consent Form-FLU SHOT and NASAL SPRAY; Below are notes about each section on the template consent forms: Section 1. dInn�$ �� >�P���X����1L�ZdS�i00�2mX+pl�-�dn�� M@d�y�-��4�E��;�0D�M� !� endstream endobj 210 0 obj <>/Metadata 16 0 R/Outlines 41 0 R/Pages 207 0 R/StructTreeRoot 46 0 R/Type/Catalog>> endobj 211 0 obj <>/MediaBox[0 0 612 792]/Parent 207 0 R/Resources<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 212 0 obj <>stream 2009 H1N1 Influenza Vaccine Consent Form for Use With Either Intramuscular, Injectable Formulation or Live Attenuated, Intranasal Formulation of Vaccine Author: Centers for Disease Control and Prevention (CDC) Subject: H1N1 flu vaccination Created Date: 10/31/2019 8:33:11 AM endstream endobj startxref I understand that in the course of the requested vaccine administration, an H-E-B Pharmacy representative could possibly be exposed to my blood or bodily fluids. hޔ�1AA��{����Q�D�� �Z�TY� ��B���/(U*�H���'� ͗393g­na�6�� In such event, I agree to review and execute the “H-E-B Post-exposure Consent for Testing” form. Consent I am providing this consent form to OccuVAX in order that I may be given the influenza vaccination. 227 0 obj <>stream 2018-2019 Student Seasonal Influenza Vaccine Consent Form.pdf. Title: Microsoft Word - FLU VACCINE CONSENT FORM 2018-2019 Author: bob.saturn Created Date: 8/10/2018 4:24:54 PM %PDF-1.5 %���� I have read and understand the information I have received concerning the possible benefits and side effects of the influenza vaccination. The most common side effects are tenderness, swelling and redness at the injection site which usually disappears within a few days. %PDF-1.6 %���� h�b``�```:� +/3�F fa�h@ӀbS~��2r&i^9�tp��> ��{� ��P%����6� �T�f1`:�v�����D�i����d%�1�4�A�sm5�fb`�������p�$D�� � �r � h�bbd```b``: "��"��L��H�f0;̖�k��I����$s7�MP�̫@"{��v%�D��4$�30*} ��� ��K endstream endobj startxref 0 %%EOF 244 0 obj <>stream 0 %%EOF h�b``�b``*c`f`��fb@ !& �X���"-���$ I hereby acknowledge that, based on the information presented to me, I am eligible to receive the influenza vaccine on this date. Section 2. 215 0 obj <>/Filter/FlateDecode/ID[]/Index[173 55]/Info 172 0 R/Length 150/Prev 51706/Root 174 0 R/Size 228/Type/XRef/W[1 2 1]>>stream I understand the risks and benefits associated with the influenza vaccine and have had any questions satisfactorily answered. Sign In. {����K��e�%�7. 173 0 obj <> endobj 2018-2019 Student Seasonal Influenza Vaccine Consent Form.pdf. Information about child to receive vaccine: This section includes suggestions for collecting personal and demographic information. 09162020 Health Operations/Forms Flu Vaccine Consent Form – 2020/2021 Date of Birth (Month/Date/Year): Age: Sex: ___M ___F Last Name: First Name: care provider. 209 0 obj <> endobj 226 0 obj <>/Filter/FlateDecode/ID[<08080550285B4E3595DBBC06D3FAC955>]/Index[209 37]/Info 208 0 R/Length 97/Prev 743068/Root 210 0 R/Size 246/Type/XRef/W[1 3 1]>>stream

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