Get Seasonal Flu Vaccine Screening Consent Form - Acphd - Acphd

Completing the Seasonal Flu Vaccine Screening Consent Form is an essential step in ensuring your health and safety regarding the flu vaccine. This guide provides clear, step-by-step instructions to help you fill out the form accurately and efficiently online.

Follow the steps to complete the Seasonal Flu Vaccine Screening Consent Form.

1. Press the ‘Get Form’ button to access the Seasonal Flu Vaccine Screening Consent Form and open it in your document editor.
2. Begin by filling out the patient's first and last name in the designated fields. This identifies the individual receiving the vaccine.
3. Provide the street address, city, zip code, and phone number of the patient for accurate contact and location details.
4. Enter the patient's date of birth to confirm their age and appropriate vaccine eligibility.
5. Indicate the gender of the patient in the respective field to assist with medical records.
6. List the mother's first name if the patient is under 18 years old, as this may be necessary for consent verification.
7. Complete the insurance information section by answering whether the patient has Medi-Cal, is American Indian or Alaska Native, and if they have private insurance that covers the flu vaccine.
8. Fill out the medical information section by answering the questions regarding current illnesses, allergies, medical history, vaccinations, and other relevant health information.
9. Review the consent statement carefully. By signing, you agree that you have read or had explained the information in the Vaccine Information Statement(s) and understand the benefits and risks of the vaccine(s).
10. Input the printed name and signature of the client or a parent/guardian if the client is under 18 years old. Also, include the date of the signature.
11. For staff use, complete the fields related to vaccine type, dose, manufacturer, lot number, expiration date, injection site, and dispensing health care provider’s signature.
12. Once all sections are completed, save your changes, and download, print, or share the form as necessary.

Complete your Seasonal Flu Vaccine Screening Consent Form online today!