Flu Vaccination Form - Central Point Pharmacy

First Name*

Last Name*

Gender*

Birthdate*

Age*

Health Card Number*

Mobile Number*

Other Contact Number

Email Address*

Emergency Contact*

Emergency Phone Number*

Screening and Questionnaire for Person to be Vaccinated

Are you sick today (i.e. a temperature > 39.5 degree C, breathing problems, active infections)?*

Yes

Do you have any allergies to eggs or egg products?*

Yes

Do you have an allergy to any of the components of the flu vaccine? (e.g. gentamicin, neomycin, kanamycin, thimerosal, formaldehyde)*

Yes

Do you take blood thinners?*

Yes

Have you had a serious reaction to the influenza vaccines in the past?*

Yes

Do you have new or changing conditions affecting the brain or nervous system?*

Yes

Have you ever had Guillian-Barré syndrome?*

Yes

COVID-19 Screening

Have a fever, cough, sore throat, runny nose, or shortness of breath*

Yes

Have travelled outside of Canada within the last 14 days*

Yes

Are a close contact of a person who tested positive for COVID-19 within the last 14 days *

Yes

Consent Information

Please read the following and provide your consent by selecting the checkbox below.*

I consent to having the presenting staff administer the seasonal influenza vaccine & read the section titled “Preparing for the Flu Shot”. I understand the risks, benefits, expected outcomes and possible side-effects of the vaccine and the pharmacist has answered all my questions regarding it. After having being administered the vaccine I have agreed to wait within the vicinity for 15 minutes and I agree to see my doctor of I develop any side effects or health problems after receiving the vaccine. I agree to having my personal health information shared with public health officials and other healthcare providers.

I am providing consent for myself

Preparing for the Flu Shot

What is influenza?
The Flu (or “influenza”) is a virus that infects the respiratory tract causing high fever, headache, muscle aches, loss of appetite and fatigue. It is spread through sneezing, coughing, shaking hands, and touching contaminated objects. In Canada, the flu season is usually from November to April.

Why get the Flu Shot?
1) It can prevent you from getting ill (the flu is much more severe than the common cold).
2) It can prevent others from getting sick (especially those at risk for serious complications).
Since the virus evolves (keeps changing), it is critical to your defense against it by getting the flu shot each year.

What can I expect from the flu shot?
The flu shot does not contain the flu, instead it has pieces of proteins from the surface so that your body can learn what it looks like. It then uses this to make memory cells & antibodies against it so that it can attack the flu quickly if you are exposed to it. This process takes 2 weeks (hence you may not have protection during this time).

Most people have no reaction to the influenza vaccine. Reactions that do occur are typically mild. Possible reactions are dependent on the type of vaccine received.

Inactivated Influenza Vaccine (Injectable)
Reactions occur within 6-12 hrs after immunization and commonly disappear within 24-48 hrs. Possible reactions are.
• Redness, mild pain and/or swelling where needle was given
• Irritability and/or tiredness
• Headache, muscle aches and pains
• Fever and chills

If you develop a fever or chills: drink extra fluids (water, fruit juice)
If your arm is sore where needle was given: place a cool compress (10 minutes on and 10 minutes off)
If you have fever, chills, headache, muscle pain and/or sore arm: check with your pharmacist/doctor and they can recommend an appropriate medicine.

As with any immunization, unexpected or unusual side effects can occur. If you have irritated eyes, breathing problems or swelling in the face call health link (8-1-1) to report the unusual event. Severe allergic reactions include hives, swelling of the face, lips or throat, wheezing and /or shock. If these occur tell someone immediately.

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