Patient Consent

for Injection & Pharmacy Record

Pharmacy Location: Bentall Centre Pharmacy Date (dd/mm/yyyy):
Patient Name: Age:
Patient Address:
Phone Number: Date of Birth: Male Female
(include area code) (dd/mm/yyyy)

Emergency Contact Name:

Contacts Phone Number: Relationship to Patient:

Provincial Health Card Number:

Family Physician Name & Number:

This section is for seasonal influenza vaccine only. By provincial legislation, Pharmacists cannot administer
a flu shot to children under a certain age. Ask your Pharmacist for age restrictions.
Childs Weight: kg OR lb I confirm that I want my child to receive the influenza vaccine.

Injection Screening Questionnaire

YES NO YES NO
Do you or have you had a fever within the past 3 days? Are you allergic to any of the following?
Eggs or egg products
Have you ever had a reaction to any immunizations Contact lens solution
previously?
Formaldehyde
Neomycin
Do you have an active neurological disorder?
Latex or natural rubber

Do you have any chronic cardiac, pulmonary or Are you taking any of these medications?
diabetic condition? Prednisone or other immunosuppressants
Coumadin (Warfarin) or other blood thinners
Are you or do you think you might be pregnant?
Phenytoin or other anti-epilepsy medications
Theophylline
Are you currently taking any prescription medications?
Do you have a history of any of the following?
Guillian-Barre Syndrome
Are you currently under a physicians care for any
Oculo-Respiratory Syndrome
medical condition?

NOTE: If you answered YES to any of the above questions, the pharmacist will ask you further questions. Pending your response,
you may not be eligible to receive an influenza vaccination today. Please speak to your physician for further information.

NOTICE OF COLLECTION
Personal information is collected under the authority of the Health Protection and Promotion Act, R.S.O.,1990 Ch. 7 and will be used to provide statistical data to the Ministry of Health and Long Term Care.
2015 McKesson Canada
 Patient Consent
for Injection & Pharmacy Record
I, the undersigned patient, parent or guardian, have read or had explained to me information about the vaccine as outlined on the
vaccine monograph. I have had the chance to ask questions, and answers were given to my satisfaction. I understand the risks
and benefits of receiving the vaccine. I agree to wait in the clinic/pharmacy for 15 minutes after getting the shot. I understand that
certain persons may have an extreme allergic reaction. If I experience such a reaction, I am aware that it may require administration
of epinephrine and/or antihistamines to treat this reaction, and that 9-1-1 will be called to provide additional assistance.

I confirm that I have read the above.

I confirm that my Pharmacist is administering the vaccine under a Medical Directive/Direct Order from my Physician
(does not apply to influenza vaccine).

Patient/Guardian Name (please print): Patient/Guardian Signature: Date Signed (dd/mm/yy):

PHARMACY USE ONLY

PHARMACIST/HEALTHCARE PROVIDERS DECLARATION: I confirm that I have communicated the risks and benefits
associated with the vaccine. I have reviewed the patient record and find that the vaccine should be given to the patient.

Administering Pharmacist Name

& Licence Number: Pharmacist Signature: Date Signed (dd/mm/yy):

Name of prescriber/authorizer of the injection:

Vaccine:

Vaccine Lot #: Expiry Date: Dosage:

Site: Date of Vaccine: Time:

Dose: Route: IM SC Site of Administration: Left Arm Right Arm

Additional Notes (including other emergency measures taken or patient follow up):

NOTICE OF COLLECTION
Personal information is collected under the authority of the Health Protection and Promotion Act, R.S.O.,1990 Ch. 7 and will be used to provide statistical data to the Ministry of Health and Long Term Care.
2015 McKesson Canada