<p> INFLUENZA & PNEUMONIA VACCINE CONSENT</p><p>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,</p><p>______is due for the following vaccination(s):</p><p>_____ Inactivated Influenza Vaccination Last given _____/_____/_____</p><p>_____ Pneumonia Polysaccharide Vaccine Last Given _____/_____/_____</p><p>Accompanying this consent are corresponding Vaccination Information Sheets indicating the reasons for vaccinations, risk factors and contraindications. </p><p>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.</p><p>I am requesting that ______a resident of ______be given the vaccinations checked below:</p><p>_____ Influenza Vaccine</p><p>_____ Pneumonia Vaccine</p><p>_____ I am not giving my consent</p><p>Signature______Date _____/_____/_____</p><p>Relationship to the Resident: _____ Self; ____ DPOA; ___Other ______</p><p>Revised 10/06</p>