Updated Flu Shot Form

Lehan Drugs We're more than medicine.
INFLUENZA VACCINE ADMINISTRATION RECORD
Your pharmacist will keep this record on file

"I have read or have had explained to me written information about the vaccine listed below. I have had an opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine being administered and authorize the administration of the vaccine to me or to the person named below for whom I am authorized to make this decision. I understand that this information will be forwarded to my physician or primary care provider."
Name
(as on Medicare or Insurance card)
Birthdate

Month Day Year
Date
Gender: M/F
E-mail
example@example.com
Address
City
State
Zip
Home phone
Doctor
Address
City
Phone
Medicare ID (as on Medicare Card, including letters)
BIN (On Pharmacy Insurance Card)
PCN (On Pharmacy Insurance Card)
Group (On Pharmacy Insurance Card)
ID (On Pharmacy Insurance Card)
Plan and number (If Medicare Advantage Plan - Otherwise leave blank)
Food/Drug Allergies
Date

Month Day Year
Date
Signature

Clear
Should be Empty:

Lehan Drugs We're more than medicine.