H1N1 CONSENT FORM

HEALTH SERVICES OF LYON COUNTY

Information about person to receive vaccine (PLEASE PRINT)
Name: Last First MI	Birth Date Age
Address: Street	Male____ Female____
City State Zip	County: Lyon
Phone Number:

Do you have an allergy to eggs or to a component of the vaccine: _____Yes _____No

______ 6 mo – 24 years old – target group

I prefer my child to have the ____Mist (if available) ____Injection

Consent for Vaccinations:

I have been given a copy and understand the Vaccine Information Sheet. I was given a chance to ask questions and my questions were answered to my satisfaction. I understand the benefits and risks of the vaccination(s). The HIPPA privacy notice will be made available upon request.

SIGNATURE:_____________________________________

************************OFFICE USE ONLY**********************

Date	Age	Site/Dosage	Manufacturer	Lot #	Administered by
	2 yo – 49 yo	Nasal	MedImmune (2 yo – 49 yo)
	6 mo – 35 mo	L R Deltoid Thigh .25 mL	Sanofi
	3 yo – 9 yo	L R Deltoid Thigh .5 mL	Novartis (4 yo +) Sanofi (6 mo +)
	10 yo – adult	L R Deltoid Thigh .5 mL	CSL (18 yo +) Novartis (4 yo +) Sanofi(6 mo +)