Sign-In Sheet # ________

INFLUENZA VACCINE CONSENT AND RELEASE FORM 2011

Please fill in the following information. Address and phone number should be for your home.
First Name M.I. Last Name

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Street Number & Address (Home)

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City State Zip Code

Phone Number (Home)

Birth Date (MM/DD/YYYY)

Age

Male Female
Company

MEDICAL INFORMATION Influenza (Flu) is a very contagious respiratory virus which causes epidemic outbreaks of varying severity almost every winter. The flu virus has the capacity to mutate from year to year, so last years vaccine will not protect you this year. Since the vaccine is made from killed virus, you cannot get the flu from receiving the vaccine. For the vast majority, the influenza vaccine will cause no side effects. The most common adverse reactions are soreness at the injection site, low grade fever, or muscle aches for 24 to 48 hours after the vaccine is given. Affiliated Physicians will only administer the influenza vaccine to pregnant women in their 2 or 3 trimesters. The vaccine you will receive contains trace amounts of thimerosal. You may wish to ask your physician about vaccines containing thimerosal prior to receiving the flu shot. You should not receive the vaccine if: You are allergic to chicken eggs, chicken, thimerosal, or have had a severe allergic reaction to prior vaccines. You have had Guillain-Barre, or currently present with a fever or viral illness. You are pregnant in your first trimester Please answer the questions below: Are you allergic to chicken, eggs, egg products? Are you allergic to thimerosal? Have you ever had an allergic reaction to flu or other vaccines? Do you currently have a fever or viral illness? Do you have an allergic reaction to latex? Do you have a history of Guillain-Barre Syndrome? (Women Only) Is there a chance you are pregnant? HIPAA Privacy Notice:
Affiliated Physicians, in accordance with HIPAA, can only disclose patient medical information for the reasons of treatment, inter-office operation and to receive payment for services. However, I understand that Affiliated Physicians may provide a record of this vaccination to my employer. As a patient, you have the right to inspect and retain copies of all medical records. As a patient, you have the right to inspect and retain copies of all medical records. You have the right to request in writing an amendment of your records, and any decision and action taken as a result of your request. You also have the right to restrict disclosure of medical information released and to whom it is released. We will record and provide to you upon request, information about any release of your information other than the use of your information for the purposes listed above. You have the right to receive a paper copy of these guidelines in full, and may receive that copy at the time of your visit, on our website at www.affiliatedphysicians.net, or by written request to the attention of the Compliance Officer. Consent: I have read the above information, and have had a chance to ask questions about flu vaccine and HIPAA compliance. I understand the benefits and risks of the influenza vaccine and request the vaccine be given to me. I understand that my participation in my employer-sponsored Flu Vaccination program is voluntary. I understand that this vaccine may contain thimerosal. I further agree to hold harmless Affiliated Physicians and my employer as well as either partys subsidiaries, officers, employees, agents, representatives, contractors, successors and assignees any claim, or action arising out of or, in any way incidental to this vaccination.
nd rd

No No No No No No No

Yes Yes Yes Yes Yes Yes Yes

Trimester: _______

X_________________________________________________
Client Signature

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Date

DO NOT WRITE BELOW THIS LINE OFFICE USE ONLY Lot No. ________ Expiration Date: _____ Manufacturer: ________ Injection Site: [ ] R Deltoid 0.5 mL [ ] L Deltoid 0.5 mL VIS Provided: _______ Date: _________

RN Name: _________________________________________ RN Signature: ______________________________________