consent

1. Business Health Affiliates, Inc.
Flu Vaccination Consent Form
Flu Information
Influenza (flu) is a respiratory disease caused by influenza virus
infection. The types or strains of influenza virus causing illness
may change from year to year, or even within the same year.
People who get the flu may have fever, chills, headache, cough
and muscle aches. Most people recover completely, however,
for some, there may be severe complications.
Flu Vaccine Information
The regular flu vaccination contains killed influenza virus of the
types selected by the U.S. Public Health Service and the Center
for Biologics Evaluation & Research of the US FDA. The types
of strains of virus are those which have most recently been
causing influenza. The vaccine will N OT give you the flu
because it is NOT a live virus vaccine.
Side Effects of the Vaccine
Influenza vaccine generally causes only mild side effects that
occur at low frequency. Most commonly, there may be soreness
at the injection site, or possible fever, chills, headache, or muscle
aches. These effects usually last 24 to 48 hours. Most people
who receive the vaccine either have no, or only mild, reactions.
There is a possibility, as with any vaccine, that an allergic or
other serious reaction, even death could occur. Moreover,
untoward medical events completely unrelated to vaccine
administration may occur coincidentally in the aftermath period
following vaccination. Unlike the 1976 Swine influenza vaccine,
flu vaccinations used subsequently have not been clearly
associated with an increased frequency of Guillian-Barre
Syndrome, which is associated with paralysis.
Contraindications:
 People with an allergy to eggs
 People with an allergy to Thimerosal (contact lens
preservative)
 People who have ever been paralyzed, have an active
neurological disorder, have had Bell’s Palsy or GBS
 People with an acute illness and a high fever over 100
degrees
If you have any of the above, please notify the nursing staff. If
you have any questions, please ask now, or contact your
physician.
Reactions to the Vaccine
If you experience any significant reactions, see your private
physician immediately.
RELEASE AND WAIVER OF LIABILITY AND INDEMNITY
I, the undersigned, for myself, my heirs, executors, administrators, successors, and assigns agree to assume full responsibility for any and all risk
of bodily injury or death and/or damage to my property resulting from participation in this flu vaccination program. I further agree to release,
discharge and indemnify and hold harmless BHA Corporation, my employer, its agents, servants, employees, representatives, assigns and
successors from any and all claims of liability which arise out of or are in any way related, directly or indirectly, to my participation in the flu
vaccination program. I understand that by signing this document, I am solely responsible for myself and others for any and all claims which
might arise in the future in connection with my participation in this program.
I have read the information on this form about influenza and influenza vaccine. I have had a chance to ask questions which were answered to my satisfaction. I believe I understand the benefits and risks of
influenza vaccine and request that the vaccine be given to me or to the person named below for whom I am authorized to make this request.
Information from Person to Receive Vaccine BHA Inc. Use Only
Are you over the age of eighteen ____________________________
Name (PLEASE PRINT) Yes___ No ___ Company Name (& Site)
___________________
Date Vaccinated
Address Street City State Zip
_____________________
Manufacturer & Lot #
___R L Deltoid
Signature (Person Receiving Vaccine or Guardian) Date Site of Injection
_____________________________
Translator: ___________________________________________ Nurse’s Signature
Print Signature