Flu Vaccine 2021 Consent Form
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.
Sign in to Google to save your progress. Learn more
Name of patient: *
Name of parent if patient is a child (under 19):
Your Care Card Number (PHN) *
Patient's date of birth: *
Family doctor: *
Please read the following carefully and answer each question *
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?
Clear form
Never submit passwords through Google Forms.
This form was created inside of Forward Care Medical. Report Abuse