Please indicate * City Employee Board of Education Employee Other Name * Date of Birth * Phone Number * Address * City and State * Zip code * Gender * Female Male Medicare # Patient History Do you currently have a health condition ( heart disease, kidney disease, asthma, anemia, or other blood disorders)? * Yes No Are you currently pregnant? * Yes No Are you a health care worker? * Yes No Have you ever had a serious reaction to eggs or previous dose of influenza vaccine (welts, swollen tongue, difficulty breathing, decreased blood pressure, etc.?) * Yes No Have you ever had Guilliain-Barre Syndrome? * Yes No Do you have a weakened immune system due to disease or medication? * Yes No Vaccine to be given: Influenza vaccine/flu shot * Yes No Please read and print the Vaccine Information Sheet (VIS) listed below for the vaccine you plan to have administered to you. This information provides you details on the disease and the vaccine along with its benefits and risks. VIS/Influenza Information Sheet I have read (or had explained to me) the information sheet about the influenza vaccine (flu shot). I have had a chance to ask questions which were answered to my satisfaction and I understand the benefits and risks of the vaccination as described. I request that the influenza vaccine be administered to me (or the person above for whom I am authorized to make the request). * Yes No Please type your name in the box as signature to receive immunizations or person authorized to make the request * Today's date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20222023202420252026 Leave this field blank
