Adult Flu Vaccine Waiver

Saugatuck Pediatrics LLC

191 Post Road West, Suite 201

Westport, CT 06880

www.saugatuckpeds.com

Phone (203) 793-4747

Fax (877) 809-0848
We can administer influenza vaccine to adults and caregivers for a fee of $60. We cannot submit this charge to your insurance, but can provide a reciept for your records.
Do you currently have a fever over 100F?*
Are you taking aspirin or aspirin containing medications daily?*
Are you known or suspected to be immunocompromised (low immunity to fight disease)*
Are you 50 years or older? (if over 50 you cannot get Flumist)*
Is there a possibility you are pregnant?*
I agree by signing below that the answers to this form are accurate and correct:
Name*

First NameLast Name
Date*

MonthDayYear
Date
NOTE: If you answered “YES” to any of the above questions, one of our clinical staff members must consult with a physician and obtain a specific written order before the vaccine can be administered.
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