If you answered YES to any of the above, the healthcare professional will have to determine if this vaccine is right for you.
I have read the above information or have had the information explained to me. I have had a chance to ask questions and these have been answered to my satisfaction. I understand the benefits and the risks of the influenza vaccine and ask that the vaccine is given to me, or to the person named above for whom I am authorized to make this request. I accept responsibility for seeking medical attention for any problems with this vaccination. I authorize billing of this vaccination to my health insurance. If for any reason my insurance does not pay for the vaccination, I agree to pay the full amount of the procedure.