Submit the completed influenza vaccine consent form to your healthcare provider. You can submit it in person at the clinic, email it to the clinic's provided email address, or fax it to the clinic's fax number. Ensure you follow the clinic's instructions for submission and retain a copy for your records. Advice: Check the clinic's specific submission requirements and contact them if you have any questions.

For the 2023/2024 influenza season, it is recommended to receive the vaccine before the flu season begins, typically in October and November. Check with your healthcare provider for specific vaccination dates and availability.

The purpose of this form is to obtain informed consent from individuals receiving the influenza vaccine for the 2023/2024 season. It ensures that recipients understand the benefits and risks associated with the vaccine. The form also provides important medical history and allergy information to healthcare providers to ensure safe vaccine administration.

• 1. Last name: The recipient's surname.
• 2. Date of birth: The recipient's birth date in year/month/day format.
• 3. Complete address: The recipient's full residential address, including street, city, province, and postal code.
• 4. Telephone number: The recipient's phone number with area code.
• 5. First name: The recipient's given name.
• 6. Chronic medical condition: Indicate and specify any chronic medical conditions the recipient has.
• 7. Allergies: Specify any allergies the recipient may have.
• 8. Consent statement: A statement confirming that the recipient understands the information provided and consents to receive the vaccine.
• 9. Signature: Signature of the recipient or legal guardian.
• 10. Legal guardian information: Name and phone number of the legal guardian, if providing consent for someone else.
• 11. For Clinic Use Only: Section for clinic staff to fill out, including vaccine details, administration date and time, dosage, route, site, lot number, expiry, and signatures.

Failure to submit this form may result in the recipient not being eligible to receive the influenza vaccine.

• Ineligibility: Without the consent form, individuals may be ineligible to receive the vaccine.
• Lack of Information: Healthcare providers will not have necessary medical history and allergy information.
• Missed Opportunity: Recipients may miss the chance to be protected against the influenza virus.

• 1. Before Vaccination: Complete this form prior to receiving the influenza vaccine.
• 2. Medical History Disclosure: Provide valuable medical history and allergy information to healthcare providers.
• 3. Legal Consent: Legal guardians can use this form to provide consent for someone else.