I have read, or had explained to me, the information sheet about influenza vaccination. I have had the chance to ask questions which were answered to my satisfaction and I understand the benefits and risk of the vaccination as described. I request that the influenza vaccination be given to me. I authorize the release of any medical or other information necessary to process a Medicare or other insurance claim or for other public health purpose.
Signature:____________________________________________________________(to be signed day of clinic)
Area Below to be Completed by Immunizing Pharmacist
Influenza Vaccine
Doctor's Name:_________________________________
Doctor's Address:_______________________________
Doctor's NPI:___________________________________
Manufacturer & Lot # __________________________________________________
Pharmacist signature:___________________________________________________