Flu Vaccine 2021 Consent Form

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Please fill out this form after you book a flu shot, but make sure to fill it out before your actual appointment day.

If you have been asked to Self-Isolate or have any Flu / Covid symptoms, such as cough, fever, difficulty breathing, sore throat, please call to reschedule your appointment.

Name of patient: *

Name of parent if patient is a child (under 19):

Your Care Card Number (PHN) *

Patient's date of birth: *

YYYY

Family doctor: *

Please read the following carefully and answer each question *

Yes

Have you ever had the flu vaccine before?

Have you ever had serious side effects from the flu vaccine?

Have you ever had Guillain Barre Syndrome?

Have you had another vaccine in the last 4 weeks?

Do you have asthma?

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