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    Flu Vaccine Form

    Uploaded by

    Eastwest Bound
    This document is a flu vaccination registration and consent form that collects client information such as name, date of birth, medical history, and contact details. It screens clients for any conditions that could impact vaccination safety like pregnancy, asthma, or allergies. It obtains consent for vaccination and disclaims the healthcare provider from liability. The form is used to record vaccine administration details including dose, lot number, site of injection, and vital signs monitoring before and after vaccination.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Flu Vaccine Form

    Uploaded by

    Eastwest Bound
    230 views1 page
    This document is a flu vaccination registration and consent form that collects client information such as name, date of birth, medical history, and contact details. It screens clients for any conditions that could impact vaccination safety like pregnancy, asthma, or allergies. It obtains consent for vaccination and disclaims the healthcare provider from liability. The form is used to record vaccine administration details including dose, lot number, site of injection, and vital signs monitoring before and after vaccination.

    Original Title

    FLU VACCINE FORM

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    This document is a flu vaccination registration and consent form that collects client information such as name, date of birth, medical history, and contact details. It screens clients for any conditions that could impact vaccination safety like pregnancy, asthma, or allergies. It obtains consent for vaccination and disclaims the healthcare provider from liability. The form is used to record vaccine administration details including dose, lot number, site of injection, and vital signs monitoring before and after vaccination.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    230 views1 page

    Flu Vaccine Form

    Uploaded by

    Eastwest Bound
    This document is a flu vaccination registration and consent form that collects client information such as name, date of birth, medical history, and contact details. It screens clients for any conditions that could impact vaccination safety like pregnancy, asthma, or allergies. It obtains consent for vaccination and disclaims the healthcare provider from liability. The form is used to record vaccine administration details including dose, lot number, site of injection, and vital signs monitoring before and after vaccination.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    FLU VACCINATION REGISTRATION AND CONSENT FORM

    (Westbound Market, Bulua, Cagayan De Oro City)

    CLIENT INFORMATION

    Full Name: _________________________________________ Date of Birth: _______________


    Sex: ________________ Age: _____________ Contact Number: _________________________
    Home Address: _________________________________________________________________

    PRE VACCINATION SCREEENING

    Yes No Details
    1. Are you well today?
    2. Do you have flu-like symptoms (e.g runny-nose, fever)
    3. Do you have any medical conditions that we should be
    aware of? (e.g Diabetes Mellitus, Hypertension)
    4. Have you received any other vaccination in the last
    months?
    5. Do you suffer from asthma?
    6. Do you have problems with previous flu shots?
    7. Are you pregnant?
    8. Do you have any Allergies?

    I have read and explained to me the vaccine information about Flu vaccine. I have a
    chance to ask question that were answered to my satisfaction. I believe I understand the
    benefit and risks of the Flu vaccine and ask that the vaccine given to me or the person named
    above for whom I am authorized to make this request.
    DISCLAIMER
    The client agrees to assume the risk of flu Vaccination and further agree to hold harmless to
    the Healthcare provider and its staff members for conducting Flu Vaccination from any and all
    claims, suits, losses or related causes of action for damages may not be held liable, including
    but not limited to, such claims that may result from my injury or death, accidental or
    otherwise, during or arising in any way from the Flu Vaccination program.

    SIGNATURE ABOVE PRINTED NAME: _____________________________________________


    DATE: ________________________________

    FOR HEALTHCARE PROVIDER ONLY

    VACCINE DOSE Lot Number Expiry Date Site/ Time Given Date
    IM Given

    Given by:

    GIFT V. PAGUNTALAN, MAN, RN


    License No: 0582653

    VITAL SIGNS MONITORING

    PRE-VACCINE V/S POST-VACCINE V/S


    Temp Temp
    O2 O2
    PR PR
    BP BP

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