Flu Shot Consent Form – Influenza Vaccine

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The flu shot consent form must be completed before a influenza vaccine is administered. The document ensures that the receiver of the vaccination is aware of the process and side effects, and that they’ve had ample opportunity to field any questions they may have. On the document there is a series of yes-or-no questions which must be answered to ensure that there won’t be any adverse side effects to the treatment. Once completed, it should be sent to the medical professional providing the flu shot.

How to Write

Step 1 – Download in Adobe PDF (.pdf).


Step 2 – Provide your full name in the first field followed by the date, your address, your phone number, your date of birth, and your email.

Step 3 – The following questions must be answered before a flu shot can be given. Select “Yes” or “No” beside each before continuing.

Step 4 – Supply the date and your signature. The information below that is for the administrator to fill in.