Non-Employee Vaccine Administration Consent Form

This form is meant for non-Atrium Health employees.

If you are vaccinating an Atrium Health teammate, please use this Vaccine Immunization Consent Form.

Consent Details:

You provided verbal consent to receive vaccines and were able to ask questions about the vaccine.

Vaccine Information Sheets (Influenza) have been provided to you and you have had a chance to ask questions which were answered to your satisfaction. To the best of your knowledge, you have no contraindications to the vaccine(s). You understand the benefits and risks of vaccine(s).

Individual Information

Vaccine Type Influenza

First Name Last Name Date of Birth Department Supervisor First and Last Name Last 4 Digits of your Social Security Number Your Contact Phone # Your Email Address

Influenza Immunization Information

Dose Type Intramuscular

Site Left Arm Right Arm

Lot Number

Manufacturer GSK

Expiration Date Administered By

Non-Employee Vaccine Administration Consent Form

This form is meant for non-Atrium Health employees.

Consent Details:

Individual Information

Influenza Immunization Information

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