Adult Workplace Flu Shot Consent Form
Personal Information
Full Name
Date of Birth
Phone Number
Email
Employer
Health Screening Questions
I have had a severe reaction to a flu vaccine before
I am allergic to eggs
I have had Guillain-Barré Syndrome
I am sick today (fever, illness, etc.)
Other Health Concerns
Consent
I have read the information about the flu vaccine. I understand the benefits and risks and hereby consent to receive the influenza vaccination.
Signature
Date