Influenza Immunization Informed Consent
This form provides patient/resident information regarding influenza and is used to document consent or declination of the influenza vaccine. It includes information regarding
Which populations are at a high risk for complications from influenza
Clinical Influenza symptoms
Possible vaccination side effects
The Vaccine Information Statement (VIS) as allows providers to designate the type of vaccine administered: standard trivalent, high dose trivalent or quadrivalent.
Color: White paper with black ink
Size: 8-1/2" x 11"
Hole Punch: 5 holes on top and side
Printed: 1 side
Quantity: 100 ea/pd