Influenza Vaccine Consent Form

Influenza Vaccine Consent Form Patient Name: [Sarah Elizabeth Johnson] Date of Birth: [15/03/1990] Address: [42 Elm Street, Anytown, AB1 2CD] Contact Number: [07700 900321] I, [Sarah Elizabeth Johnson], confirm that I have received information about the influenza (flu) vaccine. I understand the benefits of vaccination, including protection against the flu virus and its potential complications. I have been informed of the common side effects of the flu vaccine, such as soreness, redness, or swelling at the injection site, headache, muscle aches, and low-grade fever. I understand that serious allergic reactions are rare but possible. I have had the opportunity to ask questions regarding the flu vaccine, and these questions have been answered to my satisfaction by [Nurse Emily White]. I confirm that I do not have any contraindications to receiving the influenza vaccine, including: * A severe allergic reaction to a previous dose of flu vaccine or any of its components (e.g., egg protein). * A history of Guillain-Barré Syndrome (GBS) within 6 weeks of a previous flu vaccination. * Being currently unwell with a fever. (If patient has any allergies or medical conditions not mentioned above, specify here): [No known allergies or significant medical conditions affecting vaccination.] I hereby give my consent for the administration of the influenza vaccine. Patient Signature: [S.E. Johnson] Date: [01/11/2024] Administering Nurse Name: [Emily White] Nurse Signature: [E. White] Date of Administration: [01/11/2024] Vaccine Batch Number: [FLUVAX2024-56789] Injection Site: [Left Deltoid]