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2019 - 2020 Influenza Injectable Vaccine Administration Permission

  1. Gender

    Check One

  2. Does the person to be vaccinated have an allergy to eggs or to a component of the influenza vaccine?*

  3. Has the person to be vaccinated ever had a serious reaction to influenza vaccine in the past? *

  4. Has the person to be vaccinated ever had Guillain-Barré syndrome?*

  5. I have been given a copy and have read, or have had explained to me, information about influenza and the influenza vaccine to be received. I have had a chance to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine requested and ask that the vaccine be given to the person named above for whom I am authorized to make this request. I understand that if I am a BadgerCare recipient I cannot be charged an administration fee or asked for any type of donation for the administration of the influenza vaccine. Information on this form will be used to document receipt of the influenza vaccine in the Wisconsin Immunization Registry (WIR). My signature below authorizes my child to receive the initial dose of the influenza vaccine and if needed, a booster dose.

  6. Electronic Signature Acknowledgement*

    I wish to submit this influenza administration form by electronic means. By signing this permission form, I certify, that my answers are correct and complete to the best of my knowledge. I understand the questions and statements on this permission form. I understand that an electronic signature has the same legal effects and be enforced the same way as a written signature.

  7. Leave This Blank:

  8. This field is not part of the form submission.