Flu Vaccine Consent Form

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
Patient Name:*
Birth Date:*

MonthDayYear
Date
Gender (as appears on birth certificate):

MaleFemale
Address:*
Phone:*
If the patient is a minor, please list parent/guardian name:
Physician:
Please initial to give RRHC permission to administer the Influenza (Flu) Vaccine:*
Signature:*

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