Influenza Vaccine Consent Form - Motorola Solutions Mobile App

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  INOVA HEALTH SYSTEM 2700 Prospericy Avenue, Suite 100, Fairfax, VA 2203

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  CLINIC

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  I hereby give my consent, voluntarily and of my own free will, to the staff of Inova Health Syste...

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  containing A/Brisbane/59/2007 (H1N1)-like, A/Brisbane/10/2007 (H3N2)-like, B/Brisbane/60/2008-like.

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  I have read and understood “What To Do If You Have A Reaction To The Flu Shot.

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  These “seasonal” influenza vaccines are formulated to prevent annual flu.

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  I declare that I am over the age 18.

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  I am not allergic to chicken eggs.

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  I have not had Guillain-Barre syndrome or other reactions listed below from the previous vaccina...

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  I am not now sick with a fever or active respiratory infection.

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  I am not allergic to thimerosal or other mercury compounds.

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  5. I am not allergic to gentamicim, neomycin or other aminoglycoside antibiotics

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  I understand I could be at risk of having a negative reaction and therefore, I should not have it.

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  Medicare Part B Participants: I understand Inova Health System Foundation and/or its affiliates w...

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  claims on my behalf and accepts Medicare payment in full.

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  I understand that if I have assigned my Medicare benefits to an HMO/managed care plan,

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  I must receive my flu shot from my HMO/managed care provider or pay the Inova Health System charge.

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  I understand Medicare Part B.

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  I understand that the risks associated with influenza vaccine include, but are not limited to, pa...

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  or nerve pain, headache, fever, paralysis or Guillain-Barre syndrome (a kind of paralysis), encep...

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  (including anaphylactic shock or death).

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  I also understand that it is not possible to predict all possible side effects or complications w...

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  I understand that the risks associated with influenza vaccine.

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  I understand the the vaccination is being given by Inova Health System.

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  The owner and/or operator of this site, their affiliates, officers, directors, employees and agents

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  expressly disclaim any responsibility to the vaccination procedure.

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  My consent is given in light of this knowledge, and in consideration of Inova Health System givin...

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  I, for myself and my heirs, administrators, trustees, executors,

• ...and More!