Consent Form for H1N1 Flu Shot for Children / Youth

Please read the Pandemic H1N1 Influenza Vaccine Fact Sheet below before filling out the Immunization Consent Form.

Fact Sheet: Pandemic H1N1 Influenza Vaccine

Download Consent Form

Information about Consent for Older Teens

It is preferred that children under the age of 18 provide consent for immunization from their parent or guardian.

Options:

1. The child attends the immunization clinic with their parent or legal guardian who will provide the consent.
   
   
2. The child can attend the clinic if they have a signed consent form from the parent or legal guardian. The consent form and fact sheets are available above. It is important to read the fact sheets that are available for the vaccine before the consent form is signed.
   
   
3. An older child can consent to their own immunization if they have decision making capacity*.

* Decision-Making Capacity Includes:

1. Ability to understand the information and to make a decision about receiving the vaccine
   
   
2. Ability to understand the risks and benefits of the immunization
   
   
3. Ability to understand the alternatives and risks, including the consequence(s) of not proceeding with the immunization

The immunization provider shall assess and determine if the older teen has decision-making capacity.  If they do not have decision-making capacity, consent must be obtained from the parent or legal guardian.