Lehigh Valley Health Network Influenza Vaccination Consent
This file contains the consent form for the influenza vaccination from Lehigh Valley Health Network. Users can fill out their personal information and consent to receive the flu vaccine. It includes important screening questions and instructions for submission.
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How do I fill this out?
Filling out this form is straightforward. Begin by providing your personal details, including your name and contact information. Then, answer the screening questions to ensure eligibility for the vaccine.
How to fill out the Lehigh Valley Health Network Influenza Vaccination Consent?
1
Review the consent form carefully.
2
Fill in your personal information accurately.
3
Answer all screening questions honestly.
4
Sign and date the form at the bottom.
5
Submit the completed form as per instructions.
Who needs the Lehigh Valley Health Network Influenza Vaccination Consent?
1
Employees of LVHN who require vaccination documentation.
2
Parents filling out consent for their children under 18.
3
Volunteers participating in health programs that need proof of vaccination.
4
Contracted service personnel who are required to show proof for health compliance.
5
Patients who need to acknowledge understanding of the vaccination process.
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What are the instructions for submitting this form?
To submit this form, ensure that all fields are filled out completely, including the consent signature. You can either email the completed PDF to the designated address at LVHN, fax it to the provided number, or submit it in person at your nearest LVHN facility. Always keep a copy of the submitted form for your records.
What are the important dates for this form in 2024 and 2025?
Important dates for the 2024 flu vaccination season will be released closer to the start of the season, typically around September. Keep an eye out for announcements regarding specific vaccination clinics and deadlines for form submissions. It's crucial to stay informed to ensure timely vaccinations.
What is the purpose of this form?
The purpose of this form is to obtain informed consent from patients receiving the influenza vaccine at Lehigh Valley Health Network. It ensures patients understand the benefits and risks associated with the vaccine. Additionally, it helps maintain a record of those vaccinated for health compliance.
Tell me about this form and its components and fields line-by-line.
- 1. Name: The full name of the individual receiving the vaccine.
- 2. Date of Birth: The birth date to verify age eligibility.
- 3. Address: Residential address for contact purposes.
- 4. Phone: Contact number to reach the individual.
- 5. Email: Email for any further communication regarding the vaccination.
- 6. Legal Sex: Legal identification of sex for health records.
- 7. Doctor's Name: The name of the individual's primary healthcare provider.
- 8. Vaccination History: Questions related to past vaccinations and health history.
- 9. Consent Signature: Signature to acknowledge understanding and consent.
What happens if I fail to submit this form?
Failure to submit this form can result in delays or inability to receive the influenza vaccine. It is important to complete all sections accurately to ensure eligibility. Without the signed consent, you will not be allowed to participate in the vaccination program.
- Delays in Vaccination: Without timely submission, you may miss your vaccination opportunity.
- Ineligibility for Vaccine: Incomplete forms can lead to your ineligibility to receive the vaccine.
- Liability Issues: Unsigned consent forms may expose stakeholders to liability.
How do I know when to use this form?
- 1. For Employees: To comply with workplace health policies regarding vaccination.
- 2. For Minors: Required for parental consent for underage vaccinations.
- 3. For Volunteers: Ensures they are up to date with health compliance requirements.
Frequently Asked Question
How do I fill out the consent form?
Simply enter your information in the designated fields and answer all the questions.
Can I edit the form after I've downloaded it?
Yes, you can reopen the form in the PrintFriendly editor to make changes.
How do I submit the consent form?
Follow the submission instructions included at the end of the form.
Is my consent form secure?
Yes, your information is handled with care when using our editing services.
What information is required to complete this form?
You need to provide basic personal details and answer vaccination screening questions.
Can I use this form for my child?
Yes, parents or guardians can fill it out on behalf of minors.
What if I have questions about the vaccine?
Consult your healthcare provider for guidance on vaccination.
Is there an expiration date for the consent?
Yes, the form needs to be current for the vaccination season.
How can I share this PDF once it's completed?
You can directly share it via email or social media through PrintFriendly.
What happens if I forget to sign the form?
Ensure you sign it before submission as it's required for consent.
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