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Influenza Vaccine Consent Form

Family Healthcare of Fairfax, PC

Influenza (Flu) is a respiratory disease caused by influenza virus infection. The types or strains of influenza virus causing illness may change from year to year, or even within the same year. People who get the flu may have fever, chills, headaches, dry cough, and muscle aches, and may be sick for several days to a week or more. Most people recover completely. However, for some people, flu may be especially severe, and pneumonia or other complications including death may develop.

Flu Vaccine- The regular flu vaccine contains inactivated influenza virus of the types selected by the US Public Health Services and Center for Biologics Evaluation & Research of the US food and Drug Administration. The types or strains of the virus included are those that have most recently caused influenza. The vaccine will NOT give you the flu because it is an inactive virus vaccine. As with any vaccine, flu vaccine may not protect 100% of all susceptible individuals.

Risks & Possible Side Effects- Influenza vaccine generally causes only mild side effects that occur at low frequency. Most commonly, the reactions may be a sore or tender arm at the injection site, or possible fever, chills, headache, or muscle aches. These effects usually last 24-48 hours. Most people who receive the vaccine either have none or only mild reactions. Side effects may be more frequent after vaccination with Fluzone High-Dose vaccine. There is a possibility, as with any other vaccine or drug that an allergic or other serious reaction or even death could occur. Moreover, untoward medical events completely unrelated to vaccine administration may occur coincidentally in the aftermath period following vaccination.

Unlike the 1976 swine influenza vaccine, flu vaccines used subsequently have not been clearly associated with an increased frequency of Guillain-Barre Syndrome that is associated with paralysis.

SPECIAL NOTICE Vaccination is generally not recommended for the following people: 1. People allergic to eggs or egg products. 2. People sensitive to Thimerosal (mercury derivative). 3. People who have an active neurological disorder. 4. People with a fever, acute respiratory, or other active infections/illnesses.

If you have any of the above, please notify the staff. If you have any questions, please ask now or check with your physician before receiving the vaccine. If you experience any significant reactions, see your physician.

I have read the above information about influenza and influenza vaccine and I have had a chance to ask questions. I understand the benefits and risks of influenza vaccination and request that the vaccine be given to me or the person named below for whom I am authorized to sign.

By typing your name, you agree to the above statements.
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