Inactivated Influenza Vaccine Consent and Release Form
Print Name: ______________________ M. Initial _______ Last Name: _______________________
Address: _____________________________ City: ___________ State: _______ Zip: ___________
Phone: ( )__________________ Birth date: ______/_____/_____ Age: _______ Sex: M __ F ___
Emerg. Contact Name: ________________________ Phone: ( ) ___________________
1. The Disease. The influenza vaccine is recommended for individuals who wish to reduce their
chances of becoming infected with influenza. Influenza (flu) is caused by viruses. When people get the
flu, they may have fever, chills, headache, dry cough or muscle aches. Illness may last several days or a
week or more and complete recovery is usual. However, complications may lead to pneumonia or death
in some people. For the elderly and people with diabetes or heart, lung, or kidney diseases, flu may be
The vaccine is highly recommended for the following high risk individuals:
*Adults with heart disease, lung disease, kidney disease, diabetes, or anemia.
*Adults with impaired breathing or swallowing capacity from muscle or nerve disorde3rs such as
cerebral palsy or seizure disorders.
*Person over the age of 50
2. The Vaccine. Today’s flu vaccines cause fewer side effects than those used in the past. In contrast
with some other vaccines, flu vaccine can be taken safely during pregnancy; however, flu vaccine should
be given to pregnant women according to the chronic illness criteria applied to other persons. One shot
will protect most people from influenza during the next flu season.
3. Possible Vaccine Side Effects. Most people will have no side effects from the vaccine. However,
tenderness at the site of the shot may occur and last for several days. Some people will also have fever,
chills, headaches, or muscle aches within the first 48 hours. As with any vaccine or drug, the possibility
of severe or potentially fatal reactions exists. However, flu vaccine has rarely been associated with
severe or fatal reactions. In 1976, an uncommon illness characterized by ascending paralysis (Guillain-
Barre’ Syndrome, or GBS) has been reported following other flu vaccines. Since then, flu vaccines have
not been clearly linked to GBS: however, it must be assumed that the risk is present., In comparison to
the risk of influenza and its complications, the risk of GBS is much lower, and this factor should be
considered when deciding whether to receive the flu vaccine. Hypersensitivity reactions t any vaccine
component can occur. Exposure to vaccines containing thimerosal can lead to induction of
hypersensitivity. When reported, hypersensitivity to thimerosal has usually consisted of local, delayed-
type hypersensitivity reactions (localized swelling and redness). In some instances people receiving
vaccine have had allergic reactions.
The following individuals should check with their primary care physician before taking the influenza
*Persons with allergy to egg, or egg products, that causes a dangerous reaction if they eat eggs, and
those who have had a serious reaction to previous flu vaccines.
*Anyone who has had an allergic reaction to the flu vaccine or other vaccine.
*Anyone allergic to thimerosal or mercury or latex.
*Anyone who has ever had Guillain-Barre’ Syndrome.
*Women who are or might be pregnant.
*Persons who are ill and have fever or a current respiratory infection.
*Persons with bleeding/coagulation disorders and/or who are on blood thinners.
*Anyone who is immune-suppressed (taking steroids, undergoing chemotherapy, etc.).
If you have any questions about influenza or influenza vaccine, please ask now or call your doctor before
requesting the influenza vaccine.
I acknowledge that I am voluntarily and knowingly requesting an influenza vaccination (”Vaccine”) from
a pharmacist employed by Life Worth Living Pharmacy.
I agree to contact my primary doctor or Life Worth Living Pharmacy if I have any concerns or an adverse
reaction to the flu vaccination. If I am receiving a flu vaccination for the first time, I agree to remain at
the pharmacy for 15 minutes after receiving my vaccination in order to be monitored. Should I
experience any of the following shortly after receiving the Vaccine: shortness of breath, difficulty
swallowing/swelling in the throat or chest, pain/tightness, or any swelling or redness at the injection
site, I will immediately report back to the pharmacy for follow-up. I acknowledge that Life Worth Living
Pharmacy has given me a copy of the Vaccine Information Statement that contains information about
the Vaccine, including information on certain adverse reactions that I may experience as a result of
receiving the Vaccine. I have read and understand the Vaccine Information Statement and this form
about influenza and the influenza vaccine, and I have had the chance to ask questions about the
contents of the Vaccine Information Statement and this form. I understand and agree that Life Worth
Living Pharmacy may be required by applicable law to report certain information without notice to me
about my vaccination to the appropriate state and federal regulatory authorities for purposes such as
reporting of adverse events or immunization registries.
I understand and have considered the benefits and risks of the Vaccine, and I believe that benefits of
receiving the Vaccine outweigh the risks associated with receiving the Vaccine. I hereby consent to have
the Vaccine administered to me by the Life Worth Living pharmacist.
I further agree to hold harmless Life Worth Living Pharmacy and its subsidiaries, officers, employees,
agents, representatives, contractors, successors and assignees from any claim or action arising out of or,
in any way incidental to this vaccination. I am 18 years or older, under no duress, and have read and
understood this informed consent for influenza virus vaccination. I will communicate the information
provided to me today about my vaccination to my primary care provider, if I have one.
By signing below, I certify that the following statements are true:
*I am the patient or the patient’s guardian/personal representative signing on behalf of the patient.
*I read, understand and agree to all the statements on this form.
Print Name Signature of Patient
Date Signed Signature of Patient’s Legal Guardian/Personal (if applicable)
Life Worth Living Use Only
1. Allergy to chicken eggs, egg products, or any
other allergies? Yes ____ No ____ Unknown ____
2. Had flu shot before? Yes ____ No____ Unknown ____
3. Prior allergic reaction to any vaccine? Yes ____ No ____ Unknown ____
4. Currently sick/fever? Yes ____ No ____ Unknown ____
5. Vaccination in past 14 days? Yes ____ No ____ Unknown ____
6. Thimerosal/mercury or latex allergy? Yes ____ No ____ Unknown ____
7. Pregnant, might be pregnant, planning to become
Pregnant in next 4 weeks? Yes ____ No _____Unknown____
8. Ever had Guillain-Barre’ Syndrome? Yes _____ No _____ Unknown____
9. Bleeding disorder? Yes _____ No _____ Unknown____
10. Live with, expect to live with, or have close contact with
Immune-compromised person who must be in protective
Isolation? Yes ____ No ______ Unknown____
Vaccine _______________________ Date of VIS _____________ Date VIS given ____________
Lot # _____________________________________
Expiration Date _______________ __________________________________ _____________
Signature of person administering vaccine Date Given
Left Arm ________________ Right Arm ____________________
Florida Standing Orders – Vaccination Standing Order Protocol
Authority to Immunize
Authority to Initiate Immunization
Date: _____________, _________
I, Dr __________________________________, for the purpose of facilitating the immunization of
individuals 18 years of age and older in the state of Florida against preventable disease in accordance
with current guidelines established by the Centers for Disease Control and Prevention’s Advisory
Committee on Immunization Practices (“CDC-ACIP”), in compliance with the state of Florida Board of
Pharmacy, Medicine and Osteopathic Medicine statutes and regulations and in collaboration with the
qualified licensed pharmacists employed by Life Worth Living Pharmacy and by executing this
Agreement issue this Vaccination Standing Order Protocol (“VSOP”) upon the following terms and
A. I represent that I am licensed to prescribe legend drugs in the state of Florida and am in good
standing with the appropriate state medical board.
B. This VSOP is intended to constitute my prescription for the administration to patients 18 years
of age and older within the state of Florida, of inactivated influenza vaccine, live attenuated
influenza vaccine (LAIV) (intranasal), any additional items as described below, as well as the
standing order for Epinephrine in emergency situations as described more fully under “Protocol
for Management of Severe Allergic/Anaphylactic Reactions” below; or in the form of a pre-
measured auto-injector at dosages described in the manufacturer’s package insert. Other
vaccines or items may be added or deleted from time to time pursuant only to applicable
regulation in writing from the undersigned.
C. I delegate authority to all appropriately certified pharmacists employed by Life Worth Living
Pharmacy licensed in the state of Florida for patients under his/her care for the above
referenced vaccines and emergency situations and to administer the vaccines, and other items
described below, and/or Epinephrine, according to the current written guidelines and
immunization schedules published by the CDC-ACIP. All administration shall be conducted in
accordance with the protocols and limitations published by the CDC.
D. This VSOP shall apply only to patients age 8 years of age or older.
E. This VSOP authorization is conditioned upon the certified pharmacist(s) properly screening
patients for receipt of the vaccine based upon guidelines that may be set forth by the CDC-ACIP.
No patient shall receive vaccine that fails to meet criteria, has a medical contraindication to
vaccine, an allergy to components of the vaccine or prior history of a reaction to a vaccine. Each
vaccine recipient must be informed by the administering pharmacist of the potential benefits
and risks of the vaccine. This disclosure must be documented by the execution of an Informed
Consent form by each recipient of the vaccine (or by the parent/guardian if permitted by state
F. All patients shall be provided with a copy of the most current federal Vaccine Information
G. All vaccines hall be administered and stored according to the directions of the manufacturer and
the FDA approved Prescribing Information. The pharmacist will administer the appropriate dose
of the live attenuated intranasal vaccine or injectable vaccine intramuscularly in the upper
deltoid muscle or subcutaneously if recommended by the manufacturer. If a patient is to
receive more than one vaccine on the same day, the injections shall be administered in opposite
EXCEPTION: If a patient has been instructed by his/her physician, in writing, to receive
injections in only one arm due to radical mastectomy or other medical reasons, and the patient
is indicated to receive more than one vaccine on the same day, the injections shall be
administered in the same arm at sites separated by at least one (1) inch.
H. Following immunization, the pharmacist shall recommend patients remain under observation
for at least fifteen (15) minutes, in accordance with state and local regulations, to monitor for
adverse events. The pharmacist shall instruct the patient to report any adverse events to them
after receiving the vaccine.
I. Sharps and syringes shall be disposed in an approved “sharps” container using universal
precautions. All full containers shall be disposed of according to state regulations.
J. Records of each immunization shall be documented and maintained in accordance with state
and federal regulations. A personal immunization record card shall be given to each patient
with a record of the date of vaccination and the name/location/telephone number of the
administering pharmacy. An immunization notification letter shall be mailed at the patient’s
request to the patient’s primary care physician for all vaccinations.
K. All adverse reactions to the vaccine shall be submitted to the FDA and the CDC via the Vaccine
Adverse Events Reporting System (V”VAERS”) form with a copy of each report provided to the
patient’s primary care physician, and to the physician signing the VSOP.
L. Physician’s entering into a collaborative protocol with Life Worth Living Pharmacy shall be
provided immunization information including patients that were administered vaccine provided
under the VSOP on an annual basis or as requested by the physician. The physician signing the
VSOP shall be notified of the indicated vaccine administered, the patient’s name, the date
administered, and the location of where the indicated vaccine was administered.
M. Life Worth Living Pharmacy will defend and hold harmless the physician signing this VSOP form
and against claims based on acts or omissions of Life Worth Living Pharmacy and its personnel
relating to this VSOP; the physician agrees to give prompt written notice to Life Worth Living
Pharmacy of any such claims that he/she may receive. Life Worth Living Pharmacy shall
continue to maintain insurance or self-insurance adequate to cover against its liability for any
such claims. Life Worth Living Pharmacy shall add the physician signing this VSOP as an
additional insured on such coverage, and provided the certificate of insurance to document this.
N. This VSOP may be terminated at any time by either party in writing on ninety (90) days prior
notice; except in the vent either party, in its sole reasonable discretion, believes it necessary to
terminate immediately in writing without prior notice in order to prevent harm. If either party
believes the other may be in breach of this VSP, it shall give a written notice to the other party
who shall have thirty (30) days to show that any such breach has been cured.
O. The initial term of this Agreement shall commence on the date set forth on the first page of this
VSOP and shall continue in effect for one year, unless terminated pursuant to the terms of this
Agreement. Thereafter, this Agreement shall automatically renew for up to two (2) consecutive
one (1) year renewal terms, unless either party notifies the other party of its intention not to
renew this Agreement at least ninety (90) days prior to any renewal date of this Agreement or
this Agreement is earlier terminated as provided herein.
P. Notices shall be in writing, effective on delivery. Notices to the physician shall be addressed Life
Worth Living Pharmacy, 6488 Currin Drive, Orlando, FL 328____.
Physician: ___________________________ Date: ____________________
Printed Name: ________________________ FL License No.: ____________________
Address: __________________________________ DEA No.: _________________________
City, State, ZipCode: _________________________ UPIN: ____________________________
PHARMACIST’S VERIFICATION AND ACCEPTANCE
I, ________________________________________, pharmacist license #_________________________,
by signing below and acting as an agent for the physician under the foregoing VSP Standing Orders,
declare the following:
1. I am a certified pharmacist who has successfully completed the Influenza Immunization
Certification Program and otherwise satisfied the requirements of Section 465.89, Florida
Statutes, and Rule 64B16-26.1031, Florida Administrative Code.
2. I maintain current certification in Cardiopulmonary Resuscitation from the American Red Cross
or equivalent. I receive annual training in Occupational Safety & Health Administration
Bloodborne Pathogens and Needlestick Prevention.
3. I maintain competency in the disease states, drugs and the administration of immunizations.
Pharmacist: ______________________________________ Date: ________________
Printed Name: ____________________________________
Pharmacy Address: ___________________________________________________________
City, State,ZipCode: ___________________________________________________________
Pharmacy Phone No.: _________________________________________________________
Protocol for Management of Severe Allergic/Anaphylactic Reactions
If an allergic reaction to a medication occurs, the following standing orders will be used:
- Be prepared to call 911
- Take a thorough history for allergies and prior adverse events before any immunization.
- Allow adequate physical space for a patient’s fainting or collapse without injury and for
placing a patient flat on a hard surface if cardiopulmonary resuscitation (CPR) is needed.
- Maintain current competency in immunization and CPR; observe all vaccinees for a suitable
period of time after immunization; remind vaccinees to report any adverse events to you.
2. Supplies to Stock
- Epi-Pen(s) – at least two adult EpiPens will be in stock and two EpiPen Jrs
3. Recognition of Anaphylactic Reaction
- Sudden onset of itching, redness with or without hives, within several minutes of
administering a medication. The symptoms may be localized or generalized.
- Angioedema (swelling of the lips, face, throat)
- Bronchospasm (shortness of breath), shock
4. Emergency Treatment
- If itching and swelling are confined to the extremity in which the immunization was
administered, observe patient closely for a suitable period, watching for generalized
symptoms. If none occur, go to the last bullet point below.
- If symptoms are generalized, activate the emergency medical system (EMS) (e.g., call 911)
and call the consulting physician for instructions. These calls should be made by another
person, while the immunizer treats and observes the patient.
STAY ON THE LINE
- The pharmacist is to administer epinephrine according to the dose on the table below,
subcutaneously or intramuscularly. The site of administration is the anterolateral aspect of
the thigh (outer thigh), through clothing if necessary.
- Monitor the patient closely until EMS arrives. Perform CPR and maintain airway, if
necessary. Keep patient in supine position unless he or she is having breathing difficulty. If
breathing is difficult, patient’s head may be elevated, provided blood pressure is adequate
to prevent loss of consciousness. Monitor vital signs frequently.
- If EMS has not arrived and symptoms are still present, repeat dose of epinephrine every 5
to 20 minutes, depending on the patient’s response.
- Refer the patient for medical evaluation, even if the symptoms are completely resolved.
Symptoms may reoccur after epinephrine and diphenhydramine war off, as much as 24
hours later. After the event is concluded. Complete a Vaccine Adverse Event Reporting
System (VAERS) form.
- The pharmacist must notify the patient’s primary care physician within 24 hours of the
5. Epinephrine Dosing
(Dosing by body weight is preferred)
(The standard dose is 0.01 mg/kg body weight, up to 0.5)
Age Group Weight (kg) Weight (lbs) Epinephrine Dose
>12 years >45 >99 See Below
Adults: Inject 0.3mg intramuscularly or subcutaneously into the anterolateral aspect of the
thigh, through clothing if necessary. Repeat injection with additional epinephrine auto-injector
(EpiPen Auto-injector delivers 0.3mg epinephrine injection (0.3ml, 1:1000) and is intended for
patients who weigh 30Kg or more (approximately 66 pounds or more)
Children (under 12 years of age): Dosage based on patient body weight: 15 to 29 kg, 0.15mg;
30 kg or more, 0.3mg. Administer intramuscularly or subcutaneously into the anterolateral
aspect of the thigh, through clothing if necessary. Repeat injection with an additional
epinephrine auto-injector if necessary.
(EpiPen Auto-injector delivers 0.15mg epinephrine injection (0.3ml, 1:2000) and is intended for
patients who weigh 15 to 30Kg or more (33 to 66 pounds)
Physician: __________________________________ Date: ___________________
Pharmacist: ________________________________ Date: ___________________
Bloodborne Pathogens Program Decision Flow Charge
Does the following apply? No
Associates may reasonably be exposed to
blood or other potentially infectious No further action required.
materials while performing job tasks.
Include associate’s job classification
and job tasks on list within this
Bloodborne Pathogens Program
Has hepatitis B vaccine been
Administer hepatitis B vaccine or have
waiver signed indicating decline of Yes
Attend blood-borne pathogen
Attend annual refresher training