I have read or have had explained to me the Vaccine Information Statement about influenza and the influenza vaccine. I have had a chance to ask questions that were answered to my satisfaction. I believe I understand the benefits and risks of the influenza vaccine and ask that the vaccine be given to me or the person named above for whom I am authorized to make this request (parent or guardian). I understand that with all vaccines there is no guarantee that I will become immune or that I will not experience side effects. I understand that one should not receive this vaccine if they have a severe allergy to eggs, have had a severe reaction to a previous influenza vaccine, or if they have had Guillian-Barre Syndrome. I hereby request the influenza vaccine for the 2019 flu season, be given to myself, or the person for whom I am authorized to give consent.