Flu Form

School Influenza Vaccine Consent Form

Please call 573-324-2111 for any questions or concerns. or email Jeannie Stuckey at jstuckey@pikecountyhealth.org
Please select one:

StaffStudent
Please Select the School your Child attends*

BG Middle/High School 10/29/2025Louisiana Elementary School on 10/08/2025Louisiana Middle/High School on 10/09/2025Clopton School on 10/02/2025Boncl 09/25/2025Van-Far School on 10/07/2025
Name of Person to be vaccinated*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Date of Birth*

MonthDayYear
Date
Allergies
Gender*

MaleFemale
Race*
Preferred Language:*
Ethnicity*

Not HispanicHispanic
Name of Parent/Guardian*

First NameLast Name
Address same as Child's*

YesNo
Parent/Guardian Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Relationship to Child*
Phone Number*
Please enter a valid phone number.
For Patients: The following questions will help us determine if you may be given a vaccine today. If you answer “YES” to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions must be asked. If a question is not clear, please ask you healthcare provider to explain. (These questions will also be asked to your child the day of vaccination clinic)

Flu Vaccine *

	Yes	No
1. Is the person to be vaccinated sick today?
2. Does the person to be vaccinated have an allergy to any component of the vaccine?
3. Has the person to be vaccinated ever had a serious reaction to ANY vaccine in the past?
4. Has the person to be vaccinated ever had Guillain-Barrè Syndrome:

Insurance Information
No Insurance or Under insuredAmerican Indian or Alaska NativeDoes not apply to me
Insurance Name*
Member/Medicaid ID Number*
If no insurance, put NA
Group Number*
Contact Phone # for Insurance*
Please enter a valid phone number.
Please Take Photo of the front of your insurance card here.
Please Take Photo of the back of your insurance card here.
Click this link to see CDC Vaccine Information. https://www.cdc.gov/vaccines/hcp/current-vis/index.html
By signing this form, I am stating that I have read or have had explained to me the information on this form. I believe I understand the benefits and risk of the vaccine(s). I have chosen to request the vaccine be given to me or the person named above for whom I authorized the request.
Signature*

Clear
Today's Date*

MonthDayYear
Date
Age
Should be Empty:

School Influenza Vaccine Consent Form