1. No category

Northeast Colorado Health Department
Family Consent Form
Date of Service: October 21, 2016
Direccion:_____________________________________ Ciudad, Estado y Codigo Postal____________________
Persona #1
Persona #2
Persona #3
Persona #4
Persona #5
Masculino
Femenino
Masculino
Femenino
Masculino
Femenino
Masculino
Femenino
Masculino
Femenino
Nombre completo:
(Letra de molde)
Fecha de
Nacimiento
Sexo:
Relaccion:
(Madre, padre, hijo/a
hermano, hermana,
abuela, abuela, etc…)
Alergias a
medicaciones?
Si
No
Si
No
Si
No
Si
No
Si
No
Tiene alergias al
huevo?
Si
No
Si
No
Si
No
Si
No
Si
No
Si
No
Si
No
Si
No
Si
No
Si
No
Historia de GBS
(Sindrome de Guillain
Barre)
e
dmi
He leído o me han explicado la información de la Hoja de Información sobre Vacunas para la vacuna en contra de la influenza.
He tenido la oportunidad de hacer preguntas que fueron contestadas a mi satisfacción. Entiendo los beneficios y los riesgos de
la vacuna. Doy mi consentimiento para recibir la vacuna para mí mismo, mis hijos y otras personas nombrados en este
formulario. Doy mi consentimiento al plan de servicio, incluyendo los exámenes, pruebas y tratamientos por parte del personal
de NCHD.
He recibido una copia de la Declaración de Privacidad del Departamento de Salud de Noreste Colorado.
Firma de la persona dando consentimiento para el tratamiento___________________________Fecha _______________
2016-2017
Fluzone Influenza
Vaccine
VIS: 8/7/2015
Porfavor no escribes abajo de esta caja
Site: LD RD Site: LD RD
Site: LD RD Site: LD RD
Site: LD RD
LT RT
LT RT
LT RT
LT RT
LT RT
VIS: ENG SP
Lot# UI678AC
VIS: ENG SP
Lot# UI678AC
VIS: ENG SP
Lot# UI678AC
VIS: ENG SP
Lot# UI678AC
VIS: ENG SP
Lot# UI678AC
Dosage: 0.25 0.5
Dosage: 0.25 0.5
Dosage: 0.25 0.5
Dosage: 0.25 0.5
Dosage: 0.25 0.5
Administered by:_______________________________________ Date:_________________
Northeast Colorado Health Department
Family Consent Form
Dates of Service: October 21, 2016
Household Address________________________________ City, State, Zip ______________________
Person #1
Person #2
Person #3
Person #4
Person #5
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Full Name:
(please print)
Birth date:
Sex:
Relationship:
(Mother, father, son,
daughter, brother, sister,
grandmother, grandfather,
etc…)
Medication
Allergies:
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Egg Allergy:
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
History of GBS:
(Guillain-Barre)
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
e
dmi
I have read or have had explained to me the information on the Vaccine Information Statements about the vaccine. I have had
the chance to ask questions which were answered to my satisfaction. I understand the benefits and risks of the vaccine. I
consent to receive the vaccine for myself, my children, and other persons listed on this form. I hereby consent to the plan of
service, including examination/tests/treatments, by NCHD staff.
I have received a copy of the Privacy Statement for the Northeast Colorado Health Department
Signature of person consenting for treatment ___________________________________ Date _____________
2016-2017
Fluzone Influenza
Vaccine
VIS: 8/7/2015
Do Not Write Below this box
Site: LD RD Site: LD RD
Site: LD RD
Site: LD RD
Site: LD RD
LT RT
LT RT
LT RT
LT RT
LT RT
VIS: ENG SP
Lot# UI678AC
VIS: ENG SP
Lot# UI678AC
VIS: ENG SP
Lot# UI678AC
VIS: ENG SP
Lot# UI678AC
VIS: ENG SP
Lot# UI678AC
Dosage: 0.25 0.5
Dosage: 0.25 0.5
Dosage: 0.25 0.5
Dosage: 0.25 0.5
Dosage: 0.25 0.5
Administered by:____________________________________________ Date:_________________