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.
NATIVE HEALTH uses a third-party texting service for text reminders. Such communications may include, but not limited to, appointment reminders, providing test results, information about available services, customer survey requests, marketing goods and services, and other important notices related to NATIVE HEALTH and the Vaccine Administration Management System (VAMS).
Because text messaging is not a secure method of communication, there is some level of risk that text messages could be read by a third party and NATIVE EALTH cannot assure the confidentiality of information that it sends to you, or that you send to NATIVE HEALTH through text messaging. By signing this form, you are acknowledging these risks.
You are not required to agree to accept such calls or messages from NATIVE HEALTH as a condition of receiving services. I understand that NATIVE HEALTH's Notice of Privacy Practices is available online and I can access it anytime at https://www.nativehealthphoenix.org/services/medical/privacy/.
I am requesting that the immunization be given to me or the person named above for whom I am the Legal Representative.