• Influenza Vaccine Consent Form

  • Section I. Personal Information

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  • Flu - https://www.cdc.gov/vaccines/hcp/vis/vis-statements/flu.pdf 

  • Section II. Screening for Immunization

  • Section III. Consent for Immunization

  • I have been given a copy and have had explained, the information in the "Vaccine Information Statement" regarding the vaccine I am receiving today. All my questions concerning the vaccine have been answered to my satisfaction. I understand the benefits and risks of receiving the vaccine and request that it be given to me. I ask that this vaccine be administered by pharmacist, pharmacy intern, or pharmacy technician. I understand my pharmacy may submit this immunization information to the state immunization registry or appropriate healthcare provider

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  • By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.

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