Microsoft word - revised seasonal flu consent with influenza fact sheet _2 pages_ 2011.doc

Influenza Vaccine Consent (Please Print)
Clinic Location:

Health Question
Health Question
1) Are you being treated for an infection today? 6) Do you have any chronic cardiac, pulmonary or diabetic 7) Do you have an active neurological disorder? 3) Have you received an influenza (flu) vaccine before? 8) For Agriflu, are you allergic to:
Note: Children under nine years of age who are getting the seasonal flu shot for the first time require two doses of 4) Have you ever had a serious reaction to 9) For Vaxigrip, are you allergic to:
10) Are you taking any Coumadin or other blood thinners?
I acknowledge that I have read The Regional Municipality of York’s Influenza (Flu) Fact Sheet, or it has been read to me. I understand the benefits and
possible side effects of the influenza (flu) vaccine and that certain persons listed in the Influenza (Flu) Fact Sheet should not get the influenza (flu)
vaccine. I consent to the influenza vaccine being given to me or my child. In addition, I am aware that personal health information collected on this form
may be shared with another doctor or nurse if that is required for my care. Should you not want your information released to another doctor or nurse, please
check below or advise the Health Unit in writing.
If signing for someone other than yourself, you must be the appropriate substitute decision maker. Please indicate your relationship to that other person:
_____________________
Please check if you do not want your information released to another doctor or nurse. ˆ
Signature: ____________________________________
Print Name: _________________________________

Date of signature: _______________________________
Vaccine: Agriflu Vaxigrip Dosage:
FOR CLINIC
NOTES:
The information provided or attached to this form is being collected for use by the local Medical Officer of Health to maintain an immunization record on the
above named individual and to take appropriate action to prevent certain vaccine preventable diseases in the health unit. This information may be disclosed to the Ministry of Health and Long-Term Care or other health units for the purpose of the prevention of vaccine preventable diseases. For further details about this collection, you can contact the Manager of Community Clinics of the Infectious Di seases Control Division by calling (905) 830-4444, ext. 3578. For more information, please call Health Connection at 1-800-361-5653, TTY 1-866-252-9933 or visit www.york.ca/flu
Influenza Fact Sheet
What is influenza?
redness, or swelling where the shot was given that will go away in a few days. Influenza, also known as “the flu”, is a serious, highly contagious respiratory infection that is much worse If an allergic reaction is going to occur, it will usually happen within a few minutes after receiving the shot. This is why it is important to stay at the flu clinic for Seasonal flu is caused by regular flu viruses. If you 15 minutes after your shot, so the nurses can watch get the seasonal flu, you may experience a cough, fever, chills, sore throat, headache, muscle aches and fatigue. Most people who get the flu are ill for a few days, but Note: If you are ill with a fever, wait until you have
some can become very sick. Babies, very young children, pregnant women and people with serious health problems can become seriously ill. See your physician to get the flu shot if you have:
• had a serious allergic reaction to a previous dose of influenza vaccine or any component of the Flu viruses spread quickly and easily
• developed Oculo-Respiratory Syndrome (ORS) • touching unwashed hands or contaminated • ever experienced Guillain-Barré Syndrome (GBS) surfaces and objects and then touching your • A person can spread the flu from the day before becoming sick until several days afterwards Prevent the spread of the flu virus:

Wash your hands with soap and water thoroughly About the seasonal flu vaccine
• Each year there is a new vaccine to protect Use an alcohol-based sanitizer. Keep an alcohol against the flu strains that are expected in the hand sanitizer handy at work, home and in your coming flu season. Even if the strains have not car. It needs to be 60% alcohol to be effective changed, getting the flu shot every year Cough and sneeze into your upper sleeve or a tissue, not your hand. Dispose of tissues It takes about two weeks for protection to develop after receiving your flu shot, and the protection Stay home when you are sick and limit contact • The vaccine is effective in about 70 to 90 percent • Children under nine years of age who are getting Keep common surfaces and items clean and the seasonal flu shot for the first time require two doses of the vaccine, at least four weeks apart. • Experts have concluded that people who are allergic to eggs may receive the seasonal influenza vaccine. Side Effects
Serious side effects are very rare, but a few people may have mild side effects, such as soreness, For more information, please call Health Connection at 1-800-361-5653, TTY 1-866-252-9933 or visit www.york.ca/flu

Source: http://www.bayviewhill.es.yrdsb.edu.on.ca/supportcentre/documents/Flu-Shot-Consent-Form-2011-A.pdf