INFLUENZA VACCINE CONSENT FORM 2021/2022

1 INFLUENZA VACCINE CONSENT form 2021/2022 . NOTE: You must remain in the clinic area 15 minutes after the vaccination is given. Last name: _____ First name: _____. Date of birth: _____yyyy / mm / dd_____ Age: _____. Complete address: number street city province postal code Telephone number: ( )_____. Do you have a chronic medical condition? ( diabetes, severe asthma or a condition affecting your heart, lungs, immune system, and/or kidneys, etc.) (please circle) No Yes If yes, specify:_____. Do you have any allergies? (please circle) No Yes If yes, specify: _____. I have read the information about the INFLUENZA VACCINE on the back of this CONSENT form . I have had the chance to ask questions which were answered to my satisfaction.

2 I understand the benefits and risks associated with this VACCINE . I give CONSENT to Ottawa Public Health to administer the INFLUENZA VACCINE . Signature: _____ Date: _____. Are you consenting on behalf of someone else? (please circle) No Yes If yes, Legal Guardian full name: _____ Relationship: _____. Legal Guardian phone number: ( )_____. For Clinic Use Only I have used two client identifiers and the client has no contraindications to receiving the INFLUENZA VACCINE based on the review of all screening questions. Initials & Designation: _____. VACCINE : Age VACCINE Dosage and Site Lot Number and Route Expiry 6 months of age FluLaval Tetra mL. (QIV-SD, egg-based) Intramuscular Fluzone Quadrivalent (QIV-SD, egg-based) Left Deltoid _____.

3 2 years of age Flucelvax Quad Left Thigh Lot Number (QIV-SD, cell culture-based) Right Deltoid 5 years of age Afluria Tetra Right Thigh (QIV-SD, egg-based) _____. 65 years of age Expiry Fluad (TIV-adj). Fluzone High-Dose mL. Quadrivalent Intramuscular (QIV-HD, egg-based). _____ _____. Date & Time of Administration Signature & Designation Clinical notes (date and time): _____. _____. _____ Signature & Designation_____. _____ Signature & Designation: _____. INFLUENZA facts What are the contraindications to getting the INFLUENZA INFLUENZA , commonly known as the flu , is a serious VACCINE ? respiratory illness caused by a virus. It spreads through You should not get the INFLUENZA VACCINE if you are: coughing and sneezing or through direct contact with - Someone who has had a serious allergic reaction surfaces contaminated by the virus.

4 While some (anaphylaxis) to any of the components of that symptoms may be cold-like, the flu can be more serious, specific flu VACCINE with the exception of egg. Egg- causing fever, chills, cough, sore throat, headache and allergic individuals may be vaccinated against body aches. Complications are more common in young INFLUENZA using any age-appropriate product, children, the elderly and those who have chronic medical without prior INFLUENZA VACCINE skin test. conditions. Individuals who have had an allergic reaction to thimerosal may receive an age-appropriate pre- The INFLUENZA VACCINE filled syringed format of Fluzone Quadrivalent, The VACCINE contains only parts of flu virus and cannot Afluria Tetra, Flucelvax Quad, Fluzone High- give you the flu.

5 Dose Quadrivalent or Fluad (unless contraindicated). Each year the content of the VACCINE is changed by the - Someone who has had a serious allergic reaction World Health Organization (WHO) to protect against the (anaphylaxis) to a previous dose of the flu strains that are expected to circulate across the world. VACCINE . You need to receive the VACCINE every year to be - Seriously ill, until you are feeling better. protected against the flu. The 2021/2022 quadrivalent - Someone who has developed Guillain-Barr . INFLUENZA vaccines (QIV and QIV-HD) can protect against 4 Syndrome (GBS) within 6 weeks of a previous different flu viruses: two INFLUENZA A viruses (H1N1 and INFLUENZA vaccination. H3N2) and two INFLUENZA B viruses.

6 The 2021/2022 o The potential risk of GBS recurrence trivalent vaccines (TIV) protect against 3 different flu associated with INFLUENZA vaccination viruses: two INFLUENZA A viruses (H1N1 and H3N2) and one must be balanced against the risk of GBS. INFLUENZA B virus. associated with INFLUENZA infection itself and the benefits of INFLUENZA vaccination. VACCINE effectiveness varies from year to year depending on different factors, including how well the VACCINE You may be referred to a physician if you have: matches the actual strains that are circulating in the - Had a non-anaphylactic allergy or suspected community, and the age and health of the person being hypersensitivity to a VACCINE or its components. vaccinated. Protection is achieved two weeks after the - Developed Guillain-Barr Syndrome (GBS) within immunization and may last six months or longer.

7 6 weeks of a previous INFLUENZA vaccination. - A history of severe Oculo-Respiratory Syndrome The flu VACCINE is publicly funded for everyone 6 months involving difficulty breathing or wheezing of age and older who lives, works or attends school in following receipt of seasonal flu VACCINE . Ontario. The flu VACCINE is safe and recommended during - A bleeding disorder. pregnancy and breastfeeding. What are the side effects of the INFLUENZA VACCINE ? Most people have no reaction to the VACCINE . The most common side effects for the injection VACCINE can last 1-3. days and may include: - Soreness, redness and swelling at the injection site;. - Tiredness/weakness;. - Low grade fever, headache and muscle aches. Severe reactions including allergic (anaphylactic) reactions are very rare and typically occur within a few minutes to a few hours after receiving the VACCINE .

8 Oculorespiratory Syndrome (ORS) may occur in extremely rare cases.