Workplace Flu Vaccine Consent Form
Employee Information
Full Name
Date of Birth
Department
Phone Number
Email
Screening Questions
Do you have any severe allergies?
Are you currently unwell or suffering from a fever?
Have you ever had a reaction to the flu vaccine?
Have you received any other vaccine in the past 14 days?
Consent
I have read and understand the information provided to me about the seasonal flu vaccine, and give my consent for vaccination.
Additional Information
Signature
Date