Flu Vaccine: an informed consent form

When making a decision to have a flu vaccine there are several important issues to take into
account:

Reasons to have the vaccine:

 Flu vaccine prevents most cases of flu and can also prevent death from flu. So not only are
you less likely to suffer from the illness but you are more likely to live longer.
 You feel the resident or person you are making the decision for would have wanted it. That
not only would they want to prevent the illness but at this point in time prolonging their life
is important.
 By being protected against flu, you are helping make sure that there is less likely hood of the
flu being passed to others who might be susceptible.

Reasons not to have the flu vaccine:

 You feel the resident or person you are making the decision for would not have wanted it.
That at this point in time prolonging their life might just prolong their suffering and you
happy for nature to take its’ course.
 They may have never have had the flu vaccine in the past, and weren’t believers in flu
vaccination.
 That if others wanted protection against flu they would consent to the vaccine for
themselves and thus be protected. So it wasn’t essential that they be vaccinated to protect
others.

Resident’s name: DOB:

Date:

I consent to the above named resident to have flu vaccine this year: YES or NO (delete one)

Person responsible or Enduring Guardian Signature: