Covid/Flu Shot Form

Full Name

Phone

Age

Email

Address

Health Card Number

• Are you sick today? (fever, cough, breathing problems, infection, Covid symptoms)
• Do you have allergies to anything? (meds, vaccines, latex, food, etc.)
• Have you ever had difficulty breathing within 6 weeks of flu shot?
• Do you have a new or changing neurological disorder?
• Do you have bleeding problems or take a blood thinner?
• Do you have an impaired immune system?

Additional Comments

Consent by patient/guardianI understand the risks and benefits of receiving the flu shot. I agree to wait in the pharmacy for 15 minutes (or time recommended by the pharmacist) after getting the flu shot. I am aware that it is possible (but rare) to have an extreme allergic reaction to any component of the vaccine. Some serious reactions can be life-threatening and is a medical emergency. If I experience such a reaction following vaccination I am aware it may require the administration of epinephrine and diphenhydramine to treat this reaction and that 911 will be called to provide further assistance. The symptoms of an anaphylactic reaction include hives, difficulty breathing, swelling of the tongue and/or lips. In the event of anaphylaxis I (or my agent) will receive a copy of this form containing information on emergency treatments that I had received, or a copy will be provided to EMS paramedics.

I confirm I want to receive the flu vaccine/covid vaccine / I confirm I want my child to receive the flu vaccine/covid vaccine

I consent to receiving the vaccine Yes No

Guardian Name (if applicable)

Guardian Relationship (if applicable)

• Covid (Pfizer)
• Covid (Moderna)
• Covid (Pediatric)
• Flu
• Flu (nasal)