Influenza & Pneumonia Vaccine Consent

INFLUENZA & PNEUMONIA VACCINE CONSENT

Date _____/_____/_____ As a resident of this facility, you are afforded the opportunity to receive an influenza vaccine every year and pneumonia vaccine every five years. According to our records,

______is due for the following vaccination(s):

_____ Inactivated Influenza Vaccination Last given _____/_____/_____

_____ Pneumonia Polysaccharide Vaccine Last Given _____/_____/_____

Accompanying this consent are corresponding Vaccination Information Sheets indicating the reasons for vaccinations, risk factors and contraindications.

Signing the consent below, indicates that: . I have read and understand the information provided, and have had the opportunity to ask questions and have had my questions answered to my satisfaction. . I understand the benefits and risks and contraindications of the vaccines checked above. . I am authorized to request the vaccination. . I authorize the appropriate billing for the above checked vaccinations.

I am requesting that ______a resident of ______be given the vaccinations checked below:

_____ Influenza Vaccine

_____ Pneumonia Vaccine

_____ I am not giving my consent

Signature______Date _____/_____/_____

Relationship to the Resident: _____ Self; ____ DPOA; ___Other ______

Revised 10/06