2025 Staff/Student Flu Consent:
Physicians to Children is proud to partner with your local school to provide you with your yearly flu vaccine.
Consent for Vaccination:
I have read or had explained to me the 2025-2026 Vaccine Information Statement (see links below) for the seasonal influenza vaccine and understand the risks and benefits. I authorize Physicians to Children & Adolescents to bill my insurance listed below for the received service, as well as provide information to the Kentucky Immunization Registry.
Student/Staff Name:
*
First Name
Last Name
Student/Staff Date of Birth:
*
-
Month
-
Day
Year
Student/Staff Home Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student/Staff Primary Care Doctor:
*
Grade Level:
*
(Staff members please type N/A)
Please select school
*
Please Select
Nelson County Early Learning Center
Cox's Creek Elementary
Foster Heights Elementary
Bloomfield Elementary
Boston School
New Haven School
Old Kentucky Home Middle
Bloomfield Middle
Thomas Nelson High
Nelson County High
The Academy
Board of Education & Transportation
Heartland Youth Village
Astra Behavioral Health
Primary Insurance:
*
Please Select
Aetna
Aetna Better Health Medicaid
Anthem Blue Cross & Blue Shield
Caresource
Centercare
Cigna
Humana Medical Medicaid
Humana Military
Medicaid/Unisys
MultiPlan
Passport/ Molina Healthcare
Private Pay
Sagamore
UMR
United Healthcare
United Healthcare Community Plan Medicaid
WellCare Medicaid
Other: IF none of the above, please see box A and list information.
Box A: Please ONLY complete this box if you selected "OTHER" on the previous question:
Insurance Company, Policy Holders name & DOB, Policy ID/#, group #.
Policy/ID Number:
*
Group Number:
*
Primary Policy Holder:
*
First Name
Last Name
Primary Policy Holders Date of Birth:
*
-
Month
-
Day
Year
Date
Secondary Insurance:
Please Select
Aetna
Aetna Better Health Medicaid
Anthem Blue Cross & Blue Shield
Caresource
Centercare
Cigna
Humana
Humana Medical Medicaid
Humana Military
Medicaid/Unisys
MultiPlan
Passport/ Molina Healthcare
Private Pay
Sagamore
UMR
United Healthcare
United Healthcare Community Plan Medicaid
WellCare Medicaid
Other: IF none of the above, please see box A and list information.
Secondary Policy Number:
Secondary Group Number:
Secondary Policy Holder:
First Name
Last Name
Secondary Policy Holders Date of Birth:
-
Month
-
Day
Year
Date
Parent/Legal Guardian: (If over age 18, list self as first and last name)
*
First Name
Last Name
Primary Phone Number
*
Please enter a valid phone number.
Consent for Vaccination: By checking the box below, I GIVE consent for Physicians to Children & Adolescents to administer the INFLUENZA vaccine. Please select which option you wish for your child to receive:
*
FLU SHOT ( https://www.cdc.gov/vaccines/hcp/current-vis/downloads/flu.pdf?CDC_AAref_Val=https://www.cdc.gov/vaccines/hcp/vis/vis-statements/flu.pdf )
FLU MIST ( https://www.cdc.gov/vaccines/hcp/current-vis/downloads/flulive.pdf?CDC_AAref_Val=https://www.cdc.gov/vaccines/hcp/vis/vis-statements/flulive.pdf )
Patient Signature (if under 18 PARENT/LEGAL GUARDIAN Signature)
*
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