Texas Children's Hospital
Texas Children's Hospital
Employee Health Digital Assistant - Flu Vaccine Program
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Employee Info
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Consent
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Confirm

Consent to Receive Flu Vaccine at a TCH Location

Complete this form to schedule and consent to receiving your flu vaccine at a Texas Children's designated flu event.

Employee Information
Required for Texas Children's employees.
These are the 6 digits after a * or + on the back of your badge.
Consent
Please click the button above to read the Vaccine Information Statement (VIS).
  1. I am at least 18 years of age. I have read or have had explained to me the inactivated influenza vaccine "What you need to know" vaccine information sheet. I have been given the opportunity to ask questions to a health care professional about the influenza vaccine. All of my questions concerning the vaccine have been answered to my satisfaction. I understand the benefits and risks of the influenza vaccine and request that it be given to me.
  2. I affirm that I am not allergic to eggs, chicken, thimerosal, albumin products or a previous dose of the influenza vaccine. I do not have a history of Guillain-Barre Syndrome (GBS).
  3. I understand that I will be required to wait, as instructed, 15 minutes after the vaccination for observation.
  4. I understand my medical care provider may submit this immunization information to the state immunization registry.
You will receive a calendar confirmation for your selected flu event location and time.

Your consent has been recorded.

A calendar confirmation email has been sent. You can close this window now, or you may click the button below to return to the main menu.

Submitted JSON (test mode)

This is the data that will be compiled and handed off for processing. You will also be prompted to save a copy.