NATIVE HEALTH providers are required by law to report each child's vaccination information to the Arizona Department of Health Services to be kept in the Arizona State Immunization Information System (ASIIS). This information is collected to avoid receiving unnecessary vaccinations and to provide information about what immunizations have been received. You understand that you are not required to agree to the release of this information in order for the child to receive the vaccinations. If you choose to opt out, however, you (or my child) will not have access to their immunization records in ASIIS in the future for schools, college attendance, future jobs/employment, military, etc. NATIVE HEALTH will report the child's vaccination information to the ASIIS unless you opt out of the release of information by initialing below. Yes, I would like to opt out of having my child's vaccination records released to the ASIIS.
Because influenza vaccine contains only noninfectious purified viral proteins, it cannot cause influenza. Occasional cases of respiratory disease following immunizaton represent coincidental illnesses unrelated to influenza immunization.
Local Symptoms: slight tenderness, redness or induration at the site of injection lasting 1 or 2 days may occur in less than one third of recipients.
Systemic Symptoms: fever, malaise, myalgia, and other systemic symptoms occur infrequently and most often affect persons who have had no exposure to the influenza virus antigens in the vaccine (e.g., young children). These reactions begin 6 to 12 hours after immunization and can persist for 1-2 days.
Influenza vaccine is contraindicated in individuals with known hypersensitivity to eggs or chicken protein, Neomycin, or Polymyxin, or in anyone who has had a life-threatening reaction to previous influenza vaccination.
By signing below, I acknowledge and agree that: (i) I have read and understand the information on this consent form including the precautions, contraindications and adverse reactions associated with the influenza vaccines. (ii) I have answered the questions on this form truthfully and accurately. (iii) I have reviewed the Vaccine Information Sheet for Influenza (Flu) Vaccine (Inactivated) or Recombinant found at . (iv) I have reviewed the NATIVE HEALTH Notice of Privacy Practices at https://www.nativehealthphoenix.org/notice-of-privacy-practices/ and understand that I may request a paper or electronic copy be provided to me. (v) I have had an opportunity to ask questions about these immunizations and all of my questions have been answered. (vi) I agree that the benefits outweigh the risks and voluntarily consent to receive these immunizations. (vii) I assume full responsibility for any reactions that may result. (viii) NATIVE HEALTH may submit claims for services rendered to my health insurer(s), including, Medicare, Medicaid, or other insurance company, and assign benefits payable for my services to NATIVE HEALTH. To view NATIVE HEALTH's Patient Rights and Responsibilities.
I am requesting that the immunization be given to me or the person named above for whom I am the Legal Representative.