Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

2018 - 2019 Influenza Injectable Vaccine Administration Permission

  1. Gender

    Check One

  2. Insurance Status

    Check all that apply

  3. Ethnicity

    Check One

  4. Race*

    Check all that Apply

  5. Is the person to be vaccinated sick today? *

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

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

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

  9. Wisconsin Immunization Registry

    I give permission to share my child's immunzation records including those provided to School(s) with the WIR and my Immunization Provider for the purpose of maintaining a complete and accurate record to assist in assuring full immunization.

  10. 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 Medicaid/BadgerCare recipient I cannot be charged an administration fee or asked for any type of donation for the administration of the influenza vaccine.

  11. 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.

  12. Leave This Blank:

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