Influenza Vaccine Consent

Home VaccinationsInfluenza Vaccine Consent

Please complete the vaccination consent form below. A printed version will require your signature when you arrive for your appointment. Skip this step if you would like to complete the form at the time of your appointment.

At which pharmacy did you book your flu shot?*
The information provided on this form was completed by:*
- Client
- Parent
- Legal Decision Maker
- Other (on behalf of client)
Name*
First Last
Preferred Name(s)
Address*
Street Address City ZIP / Postal Code
Phone*
Date of Birth*
Year
Month
Day
Male / Female*
- Male
- Female
- Undeclared
Manitoba Heath Number (6 digit)*
PHIN (9 digit)*
Are you well today?*
- Yes
- No
If no, please describe.
Do you have any known or suspected allergies?*
- Yes
- No
If yes, please describe.
Have you ever had a serious reaction or condition following any vaccine or injection?*
- Yes
- No
If yes, please describe.
Do you have any health conditions that require regular visits to a doctor?*
- Yes
- No
If yes, please describe.
Are you taking any medications that affect blood clotting?*
- Yes
- No
If yes, please list.
Is your immune system suppressed due to an autoimmune condition (i.e. Rheumatoid Arthritis, Multiple Sclerosis) or disease (i.e. Leukemia) or treatment (i.e. high-dose steroids)?*
- Yes
- No
If yes, please describe.
Have you received a dose of a COVID-19 vaccine in the past 6 months?
- Yes
- No
Have you had a confirmed COVID-19 infection in the last 6 months?
- Yes
- No
If yes, when?
Reason for Immunization – Please check the first reason that applies (Check ONE box only)*
- Health care worker
- High risk
- Contact of high risk
- No known risk
Health care workers only - Indicate your primary work setting:*
- Long term care / PCH
- Community
- Acute Care
Health care workers only - Your facility / office name
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NOTICE: Information about your immunization will be recorded in the Manitoba immunization Monitoring System (MIMS) and used for surveillance by Manitoba health to produce immunization records, monitor vaccine uptake and how well vaccines are working., and may also be used for research. all information recorded in MIMS will be protected in accordance with he Protection or Privacy provision of the Personal Health Information Act.

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