Reception __________ Central Reg _________ School Clinic Annual Flu Vaccine Consent Form
Return to school one week prior to clinic date
Section 1: Information about Child to Receive Vaccine Please Print
Student’s Date of Birth Month______ Day_______ Year________ Student’s Doctor’s Name (Last, First) Address City Zip School Name Section 2: Insurance Information
_____Injection (shot) _____ Nasal Spray
Section 3: Screening for Vaccine Eligibility Please mark YES or NO for each question.
Has your child been vaccinated with the seasonal influenza vaccine after July 1, 2010? Does your child have a serious allergy to eggs? Does your child have any other serious al ergies? Please list:______________________________ Has your child ever had a serious reaction to a previous dose of flu vaccine? Has your child ever had Guillain-Barŕe Syndrome (temporary severe muscle weakness) within 6 weeks after receiving a flu vaccine? Has your child gotten vaccinated with any vaccine (not just flu) within the past 30 days? Vaccine____________________________ Date Given: Month_______ Day_________ Year______ Does your child have any of the following: Asthma, Diabetes (or other type of metabolic disease), or disease of the lungs, heart, kidneys, liver, nerves, or blood? Is your child on long-term aspirin or aspirin-containing therapy (for example, does your child take aspirin every day)? Does your child have a weak immune system (for example, from HIV, Cancer, or medications such as steroids or those used to treat cancer)? Was your child started on Antiviral medication before the scheduled vaccination clinic?
Section 4: Consent for Child’s Vaccination:
I have read or had explained to me the 2012-2013 Vaccine Information Statement for the seasonal
influenza vaccine and understand the risks and benefits.
I give consent to ACMC and its staff/volunteers for my child named at the top of this form to be
vaccinated with this vaccine.
Your signature below is required in order to vaccinate your child.
Signature of Parent/Guardian___________________________________________Date:_____________

Children 18 years of age or younger
Your child qualifies for vaccination through the MnVFC program because he/she:

MnVFC Eligibility Criteria
Enrol ed in MNHealthcare Program (MA, PMAP, GAMC, MnCare)1 *Underinsured patients are no longer eligible for MNVFC. Please check your insurance for coverage, you may be billed. You may also receive your vaccinations at local public health immunizations clinics. FOR ADMINISTRATIVE USE ONLY
Section 5: Vaccination Record
Date Dose
Route & Dose
Lot Number
Name and Title of Vaccine Administrator:


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