Notice: Currently, High Dose (for seniors) flu-shots are out of stock. The same will be available after Oct 26, 2020. Flu Shot Consent Form Kindly fill the below details. * are mandatory fields Personal Information First Name * Last Name * Gender * MaleFemale Email * Street Address * City * State / Province / Region * Country * CanadaAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueNamibiaNauruNepalNetherlands, TheNew ZealandNicaraguaNigerNigeriaNorth MacedoniaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPiedmont-Sardinia*PolandPortugalQatarRepublic of Genoa*Republic of Korea (South Korea)Republic of the CongoRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSchaumburg-Lippe*SenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon Islands, TheSomaliaSouth AfricaSouth SudanSpainSri LankaSudanSurinameSwedenSwitzerlandSyriaTajikistanTanzaniaTexas*ThailandTimor-LesteTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnion of Soviet Socialist Republics*United Arab Emirates, TheUnited Kingdom, TheUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Western SaharaWallis and FutunaYemenZambiaZimbabweÅland Island ZIP/Postal Code * Date of Birth * Age * Book a timeslot * 10:0010:1510:3010:4511:0011:1511:3011:4512:0012:1512:3012:4501:0001:1501:3001:4502:0002:1502:3002:4503:0003:1503:3003:4504:0004:1504:3004:4505:00 Book a Time Slot * 12:1512:3012:4501:0001:1501:3001:4502:0002:1502:3002:4503:0003:1503:3003:4504:0004:1504:3004:4505:00 Date of Booking* Weight (kg or lB)* Patient OHIP No * Patient Telephone * Name of Emergency Contact * Contact’s Daytime Phone Number * Emergency Contact’s Relationship to Patient * Contact’s Evening/Other Phone Number * COVID-19 Screening Note: Every individual who will be present during the administration of the vaccine (regardless of whether you are receiving a vaccine or not) should be screened for COVID-19. Have you travelled outside of Canada in the past 14 days? * YesNo Have you tested positive for COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate personal protective equipment? * YesNo Are you experiencing any of the following symptoms? * Fever New onset of cough Worsening chronic cough Shortness of breath Difficulty breathing Sore throat Difficulty swallowing New or unusual worsening of chronic conditions Low blood pressure for your age Decrease or loss of sense of taste or smell Chills Headaches Unexplained fatigue/lethargy/malaise/muscle aches (myalgias) Nausea/vomiting, diarrhea, abdominal pain Pink eye (conjunctivitis) Runny nose or nasal congestion without other known cause Fast heart rate For infants and young children: decreased or lack of appetite/difficulty feeding YesNo If you are older than 70 years of age, are you experiencing any of the following symptoms? * Delirium Acute functional decline Unexplained or increased number of falls YesNo Screening Questionnaire For adult patients as well as parents of children (≥ 5 years of age) to be vaccinated: The following questions will help us determine if there is any reason you or your child should not get the flu shot today. If you answer “yes” to any question, it does not necessarily mean the shot cannot be given. It simply means additional questions must be asked. If a question is not clear, please ask your pharmacist to explain it. Are you sick today? (fever greater than 39.5℃, breathing problems, or active infection) * YesNoUnsure Do not get the shot today Are you allergic to any medications including vaccines? * YesNoUnsure Are you allergic to any of the following? Check all that apply: * YesNoUnsure Your pharmacist can check whether the flu shot contains any of these potential allergens and use one which does not.ThimerosalEgg protein Are you allergic to any part of the flu shot, or have you had a severe, life-threatening allergic reaction to a past flu shot? * YesNoUnsure Speak with your MD Have you had wheezing, chest tightness or difficulty breathing within 24 hours of getting a flu shot? * YesNoUnsure Speak with your MD Have you had a reaction to eggs or egg products? * YesNoUnsure Speak to the pharmacist, you may be able to receive the flu shot but may require a longer observation period post-administration. Do you have any serious allergy to latex or natural rubber? * YesNoUnsure You can receive the flu shot but non-latex materials are to be used Have you had Guillain-Barré Syndrome within 6 weeks of getting a flu shot? * YesNoUnsure Speak with your MD Do you have a new or changing neurological disorder? * YesNoUnsure Speak with your MD Do you have bleeding problems or use blood thinners? (e.g. warfarin, low dose or regular strength aspirin) * YesNoUnsure Shot can be given but apply gentle pressure afterwards. You are not eligible to Book an appointment for Flu-Shot at the moment. Please call the pharmacy at +1 (905)-876-440 for more information. Consent Given By Patient/Agent I, the undersigned client, parent or guardian, have read or had explained to me information about the flu shot as outlined on the Flu Shot Fact Sheet. I have had the chance to ask questions, and answers were given to my satisfaction. I understand the risks and benefits of receiving the flu shot. I agree to wait in the pharmacy for 15 minutes (or time recommended by the pharmacist) after getting the flu shot. I am aware that it is possible (yet rare) to have an extreme allergic reaction to any component of the vaccine. Some serious reactions called “anaphylaxis” can be life-threatening and is a medical emergency. If I experience such a reaction following vaccination, I am aware that it may require the administration of epinephrine, diphenhydramine, beta-agonists, and/or antihistamines to try to treat this reaction and that 9-1-1 will be called to provide additional assistance to the immunizer. The symptoms of an anaphylactic reaction may include hives, difficulty breathing, swelling of the tongue, throat, and/or lips. In the event of anaphylaxis, I will receive a copy of this form containing information on emergency treatments that I had received, or a copy will be provided to my agent or EMS paramedics. I confirm that I want to receive the seasonal influenza vaccine for myself or my child.
