PLEASE NOTE: It is the responsibility of each potential flu recipient to speak to his or her primary care physician BEFORE arriving at the clinic regarding ANY questions about receiving a flu shot. Although CHI nurses will prequalify potential flu recipients by repeating the same questions found on this Consent Form, unnecessary counseling at your flu clinic will cause long lines, inconvenience those in a hurry, and increase your company's nursing fees. To further avoid delays, employees should wear sleeveless or loosely fitting tops.
FIRST TIMERS: If you are receiving a flu shot for the first time, you MUST report during the first hour.

Name________________________________________________________________________________________

Company Name and Address______________________________________________________________________

City _____________________________________________ State____________________Zip_________________

Are you at least 18 years of age? Yes_____ No_____              Sex: Male_____ Female_____

Please read and sign before receiving the flu vaccine:
The U.S. Public Health Service recommends a vaccination for any individual who wishes to reduce his or her chances of becoming infected with influenza.
The vaccine is highly recommended for the following high risk individuals:
* Adults with heart disease, lung disease, kidney disease, diabetes, or anemia.
* Adults with impaired breathing capacity from chronic obstructive lung disease, or heavy smoking, neuromuscular or orthopedic conditions.
* Persons over the age of 65

WARNING:
Some people should check with their primary care physician before taking the influenza vaccine:
* Persons with allergy to chicken, egg, or egg products, that causes a dangerous reaction if they eat chicken or eggs, and those who have had a serious reaction to previous flu vaccines.
* Anyone who has had an allergic reaction to the flu or other vaccine.
* Anyone allergic to thimerosal (in eye contact lens solution) or mercury.
* Anyone who has ever been paralyzed with Guillain-Barre Syndrome should seek advice from their physician about special risks that might exist in their case.
* Women who are or might be pregnant should seek advice from their doctor.
* Persons who are ill and have fever or a current respiratory infection should consult with their doctor on whether or not to delay the vaccination.
* Persons with bleeding/coagulation disorders and/or who are on blood thinners.
* Anyone who is immuno-suppressed (taking steroids, undergoing chemotherapy, etc.).
If you have any questions about influenza or influenza vaccine, please ask now or call your doctor before requesting the vaccine.

CONSENT:
I agree to contact my primary care doctor if I have any concerns or an adverse reaction to the flu vaccination. If I'm receiving a flu shot for the first time, I agree to remain at the flu clinic after receiving my shot for 20 minutes in order to be monitored. Should I experience any of the following shortly after receiving the flu shot: shortness of breath, difficulty swallowing/swelling in the throat or chest pain/tightness, or any swelling or redness at the injection site, I will immediately report back to the flu shot station for follow-up. I have read the information on this form about influenza and the influenza vaccine. I have had a chance to ask questions about the contents of this form, which were answered to my satisfaction. I understand the benefits and risks of the influenza vaccine and hereby consent to have the flu vaccine administered to me. I further agree to hold harmless Corporate Health Initiatives, Inc. and my employer as well as either party’s subsidiaries, officers, employees, agents, representatives, contractors, successors and assignees any claim, or action arising out of or, in any way incidental to this vaccination. I hereby state that I am 18 years or older, under no duress, and have read and understood this informed consent for influenza virus vaccination. I will communicate the information provided to me today about my vaccination to my primary care provider, if I have one.

Signature ______________________________________________________________ Date __________________

RN Use Had flu shot before? Y___N___   (If no, tell them to sit for 20 minutes.) Allergy to chicken or egg? Y___N___   Prior allergic reaction to flu/other vaccine? Y___N___   Pregnant? Y___N___     if yes: 1st __ 2nd__ 3rd__ trimester Guillain-Barre? Y___N___    Immuno-suppressed? Y___N___   Vaccine__________________________ Bleeding disorder? Y___N___   Lot #___________ Exp. Date________ Currently sick/fever? Y___N___   Left arm________ Right arm_________ Thimerosal/mercury allergy? Y___N___   RN Signature____________________________________

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