Flu Vaccination Consent Form

Flu Vaccination Consent Form — Form Fields

This healthcare template includes 6 fields. Obtain patient or guardian consent before administering a flu vaccination. Captures screening questions and consent for vaccine administration. Supports workplace flu drives, school programs, and clinical settings. Free to customize and use on ZenBuild.

• Patient / Recipient Full Name (text, required)
• Date of Birth (text, required)
• Are you allergic to eggs or any vaccine components? (multiple choice, required) — options: No, Yes – allergic to eggs, Yes – prior vaccine reaction
• Do you have a fever or illness today? (multiple choice, required) — options: No – feeling well, Yes – mild symptoms, Yes – significant illness
• Are you pregnant or planning to become pregnant? (multiple choice, required) — options: No, Yes, Not applicable
• I consent to receive the influenza vaccine (multiple choice, required) — options: Yes – I consent, No – I decline