Workplace Flu Shot Consent Form

Employee Information

Full Name

Date of Birth

Department Contact Number

Health Screening

I am not sick today (fever, cold, flu symptoms) I have not had a severe reaction to flu shots before I do not have allergies to eggs or vaccines I am not currently receiving medical treatment for immune disorders

Please mention any other health concerns:

Consent

I have read and understood the information about the flu vaccine. I have had the opportunity to ask questions, which were answered to my satisfaction. I give consent to receive the influenza vaccine.

Signature

Date