Feel Ideal 360 Flu Consent Form

2020/2021 Influenza Vaccine Consent Form and Administration Record
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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. 


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Thank you for submitting your Flu Consent Form to Feel Ideal 360.  We so much appreciate you and we look forward to seeing you soon.   

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