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COVID-19 and Flu Vaccine Consent Form

COVID-19 and Flu Vaccine Consent Form

Patient Information

Name
Name
First Name
Last Name

Vaccine Information

COVID-19 Vaccine (Spikevax JN.1):
The COVID-19 vaccine helps protect against severe illness, hospitalization, and death caused by COVID-19. Common side effects may include pain at the injection site, fatigue, headache, muscle pain, chills, fever, and nausea. Most side effects are mild and resolve within a few days.

Spikevax (JN.1) Patient Information Leaflet: https://www.medicines.org.uk/emc/files/pil.15914.pdf

Adjuvanted Quadrivalent Flu Vaccine:
The flu vaccine helps protect against the influenza virus. Common side effects may include soreness at the injection site, low-grade fever, and aches. Serious side effects are rare. It is essential to get vaccinated annually, as flu viruses change from season to season.

Adjuvanted Quadrivalent Flu Vaccine Patient Information Leaflet (for those over 65 years old): https://www.medicines.org.uk/emc/files/pil.12881.pdf

Cell-Based Quadrivalent Flu Vaccine (for those Under 65 or those with egg allergy):
The cell-based quadrivalent flu vaccine helps protect against the influenza virus. Side effects are similar to those of other flu vaccines and are generally mild.

Cell-Based Quadrivalent Flu Vaccine (Seqirus) Patient Information Leaflet: https://www.medicines.org.uk/emc/files/pil.12882.pdf

Consent

I acknowledge that I have received information regarding the COVID-19 and flu vaccines, including their benefits and potential side effects.
Vaccine preference
Please enter your full name.

Medical History

Please answer the following questions to assist in your vaccination process.
Are you allergic to eggs?
Have you ever had an anaphylactic reaction to any vaccine?
Are you currently taking any blood thinners or do you have a bleeding/clotting disorder?
Do you have a history of capillary leak syndrome?
Are you currently unwell with an acute fever?
The presence of minor infections is not a reason to postpone vaccination.

Emergency Contact Information

Name
Name
First Name
Last Name

Additional Notes

Please add any information on your medical history, how to find your address, etc. that you feel may be relevant.