Influenza Vaccine Consent

2026–2027 Influenza Season

Step 1 of 2

Patient Information

Patient Name *

Date of Birth *

Vaccine Screening

Please answer every question.

Allergies or relevant medical information

Consent

I acknowledge that I have received, reviewed, or had the opportunity to review the current Influenza Vaccine Information Statement (VIS). I understand the benefits, risks, and potential side effects of influenza vaccination, including the possibility of rare but serious reactions.

I have had the opportunity to ask questions and have received satisfactory answers. I voluntarily consent to receive an influenza vaccine appropriate for my age and health status.

Signature

Patient / Parent / Legal Representative Name *

Relationship to Patient *

Signature *

Date:

Staff Review — Influenza Vaccine Consent

Review the completed patient information before exporting the PDF.

✓

Influenza Vaccine Consent Completed

Your form is complete. Please return this iPad to the front desk staff.

Patient:
DOB:
Completed:

Front Desk Only

I verified the patient name and DOB and confirmed the PDF is uploaded to the correct Practice Fusion chart.

Save the PDF, verify the upload in Practice Fusion, then clear the form before handing the iPad to the next patient.

Front Desk Access

Enter the staff PIN.