You should only complete this form AFTER contacting Ritchie Regional Health Center (304-643-4005) to schedule an appointment.
By filling out this form and electronically signing/initialing it, you:
- Are the patient OR are the legal parent or guardian of the minor named below
- Acknowledge and understand the risks and benefits of the vaccine being administered
- Give Ritchie Regional Health Center's clinical staff permission to administer the flu vaccine