Flu Vaccination Consent Form - Southwest Utah Public Health Department

FLU VACCINATION CONSENT

Accessibility Notice: If you need assistance or an alternative format to complete form, email info@swuhealth.gov.

Notice for Non-Public Personal Data Collection at: swuhealth.gov/non-public.

This form authorizes your flu vaccination and collects required health, billing, and record information.

Patient Information

Patient Personal Details

Last Name

First Name

Middle Name

Date of Birth (mm/dd/yyyy)

Age

Gender:MaleFemale

Ethnicity:HispanicNon-Hispanic

Race Information

Address

City

State

Zip

Primary Phone

Email Address

Preferred Contact:

PhoneEmailEither

Emergency Contact Name

Emergency Contact Phone #

Emergency Contact Relationship

Insurance Information

Patient Medical Insurance Details

Relationship to Insured:

Policy Holder DOB:

Screening Questions

Flu Vaccination Screening Questionnaire	Yes	No
1. Is the person to be vaccinated sick today?
2. Does the person to be vaccinated have an allergy to an ingredient of the vaccine?
3. Has the person to be vaccinated had a serious reaction to influenza vaccine in the past?
4. Has the person to be vaccinated ever had Guillain Barré Syndrome?
5. Has the person to be vaccinated felt dizzy or faint before, during, or after a shot?
6. Is the person to be vaccinated anxious about getting a shot today?

Affirmation, Consent and Privacy INFORMATION

Legal Authorization Acknowledgement

I certify that the information I have provided is true and accurate. I consent to receiving the flu vaccine. I have been given a copy and have read, or have had explained to me, the information in the Vaccine Information Statement (VIS). I have had the opportunity to ask questions, and they were answered to my satisfaction.

Data Sharing: I understand that my/the patient’s vaccine information will be reported to the Utah Statewide Immunization Information System (USIIS) as allowed by state law.

Opt-Out: If you do NOT want the information shared with USIIS, please indicate by checking this box.

I understand that billing my medical insurance does not guarantee payment, and I am responsible for any unpaid balance.
I hereby release the Southwest Utah Public Health Department and its employees from any claims arising from these immunizations.
I have been offered a copy of the Health Department’s Notice of Privacy Practices and have had the opportunity to ask questions regarding how my health information may be used.

Signature

Print Name

Today’s Date

Relationship Details

Relationship to the Signee:

Self (18+)
Parent
Guardian

Other:

FOR OFFICE USE ONLY

Amt Paid:

Type:▢ Ins ▢ CC ▢ Cash ▢ Chk #

Clerk:

Date:

Vaccine:Flu – inject.

Lot #:

Site:▢ LD ▢ RD ▢ LVL ▢ RVL

Nurse Signature:

VIS Date: 01/31/2025

Updated: 08/25/2026

FLU SHOT FORM

FLU VACCINATION CONSENT