Flu Vaccine 2020 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.
Name of patient: *
Name of parent if patient is a child (under 19):
Your Care Card Number (PHN) *
Patient's date of birth: *
MM
/
DD
/
YYYY
Family doctor: *
Please read the following carefully and answer each question *
Yes
No
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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