For drive-up vaccines, please call 618-345-5437 when you arrive. Thanks!!!
I have been given a copy and have read, or have had explained to me, the information of the Vaccine Information Sheet (VIS) provided by the Centers for Disease Control (CDC) for each vaccine I/my child am to receive today.
I have had a chance to ask questions and they have been addressed to my satisfaction.
I understand the benefits and risks of each vaccine to be given.
I give my consent for each of the vaccines to be given to me/my child at this time.
For patients (both children and adults) to be vaccinated: The following questions will help us determine if there is any reason we should not give you or your child inactivated injectable influenza vaccination today. If you answer “yes” to any question, it does not necessarily mean you (or your child) should not be vaccinated. It just means additional questions must be asked. If a question is not clear, please ask your healthcare provider to explain it.