2018-19 Influenza Vaccine Consent Form
This document is the consent form for the 2018-19 influenza vaccine, specifically catered for pregnant women. It contains essential details about the vaccination process and important guidelines for patients. Users can download, fill, and submit this form to ensure they receive the flu vaccine safely.
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How do I fill this out?
To fill out this form, start by reviewing the information section to understand the requirements. Next, complete the eligibility screening questions, making sure to answer truthfully. Finally, sign the consent statement at the bottom of the form to authorize vaccination.
How to fill out the 2018-19 Influenza Vaccine Consent Form?
1
Download and print the consent form.
2
Review the Vaccine Information Sheet provided.
3
Complete Section I with your personal details.
4
Answer the eligibility screening questions in Section II.
5
Sign and date the form before submitting.
Who needs the 2018-19 Influenza Vaccine Consent Form?
1
Pregnant women seeking flu vaccination due to increased risk.
2
Family members of pregnant women who want to support vaccination efforts.
3
Healthcare providers wishing to administer the flu vaccine.
4
Individuals planning to visit pregnant patients who need protection.
5
Public health officials monitoring vaccination uptake in pregnant populations.
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1
Open the PDF in PrintFriendly.
2
Click on text fields to make any necessary edits.
3
Update personal and eligibility information as required.
4
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5
Download the edited PDF for final submission.
What are the instructions for submitting this form?
To submit this form, first ensure that all sections are filled out accurately. You may either fax the completed form to (847) 466-7747, or physically bring it to UpToDate Healthcare for Women at 2500 W. Higgins Rd, STE 920. You can also email the form directly to the hospital’s designated email address.
What are the important dates for this form in 2024 and 2025?
The 2018-2019 influenza season runs from October 1, 2018, to March 31, 2019. It is essential to complete this form and attend your vaccination appointment within this period. Ensure your flu vaccine is administered before the flu season peaks.
What is the purpose of this form?
The purpose of this form is to collect vital information from pregnant women wishing to receive the flu vaccine. It ensures the safety and eligibility of the patient through a screening process. Finally, the form authorizes healthcare providers to administer the vaccine while documenting consent.
Tell me about this form and its components and fields line-by-line.
- 1. Name: The full name of the individual receiving the vaccine.
- 2. DOB: Date of birth of the patient.
- 3. Pregnant: A checkbox indicating if the person is pregnant.
- 4. EDD: Expected Date of Delivery for pregnant patients.
- 5. OBGYN: The name of the patient's obstetrician.
- 6. Eligibility Screening: A series of yes or no questions to determine vaccine eligibility.
- 7. Consent: A section where the patient agrees to the terms and conditions.
- 8. Signature: The signature of the patient to confirm consent.
- 9. Date: The date the form is signed.
- 10. Manufacturer: The name of the vaccine manufacturer.
What happens if I fail to submit this form?
Failing to submit this form may prevent you from receiving the influenza vaccine. Additionally, it may hinder your ability to protect yourself and your baby from potential flu complications. It is best to ensure timely submission to avoid any issues.
- Delay in Vaccination: Without a submitted form, vaccination appointments may be postponed.
- Health Risks: Outstanding health risks exist for unvaccinated pregnant women and their babies.
- Non-Compliance: Not completing the consent may lead providers to deny vaccination.
How do I know when to use this form?
- 1. Pregnant Women: Essential for those wishing to receive the influenza vaccine.
- 2. Healthcare Providers: Aids in documenting consent and eligibility.
- 3. Public Health Monitoring: Helps gather vaccination data for public health initiatives.
Frequently Asked Questions
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What should I do if I cannot find the form?
You can search for the form on PrintFriendly or check with your healthcare provider for additional copies.
How do I know if my consent is valid?
Ensure your form is filled out completely and signed before submitting to your healthcare provider.
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You can download the form in PDF format, ready for printing or sharing.
Where do I submit the completed form?
Submit your completed form to your healthcare provider as directed on the form.
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