Flu Vaccination Consent Form

Student Name: ASHIKHA PRAVEENA BHARATHIDASAN Father’s Name: BHARATHIDASAN NATARAJAN

Std : V Occupation & Company ENGINEER & MAADEN PHOSPHATE

Mobile Number: 0548502083

The following questions shall determine your eligibility to be vaccinated today:

1. Do you feel sick today? Yes No

2. Do you have any current health conditions like Heart disease,

Respiratory problems, neurological or any other health problems? Yes No

3. If yes, list here:

4. Check below if you have any allergies to:

• Food, if yes please list here:
• Latex
• Vaccine
• Egg
• Medication, if yes please list here:

NO

I hereby certify that I am getting this flu vaccine in good health condition. The Doctor/Medical Staff has clearly explained to me the benefits, risk factors and side effects of
having this vaccination. I understand that it is not possible to predict all side effects or complications associated with receiving this vaccine. I also acknowledge that I have had
the chance to ask questions and that such questions were answered to my satisfaction. Further, I acknowledge that I have been advised to consult a licensed physician if any
side effects or complications occur after the vaccination. I further acknowledge that I hold Danat al Sahraa and Indian School Jubail free of any liability, medical or otherwise,
that may arise from this vaccination. 07-FEB-2022
Nurse: L/R Signature & Date:

Signature & Date: 07-FEB-2022