URI Campus FLU & COVID Vaccine Clinic

Covid/Flu Vaccination Registration/Consent

Choose 1 or Both (FLU, COVID, OR BOTH): Walk in on day that works best for you below.
Are you a student or Faculty/Staff?
1. Register Now.
2. Walk in on the day that works best for you below— no appointment needed (9 am to 3 pm).

Memorial Union – Ballroom

Sept 10
Sept 21
Oct 07
Oct 20

Nov 05
Nov 18
Dec 09
Jan 27
Feb 04

@ Bay Campus
October 21

@ Mackal Field House
October 30
Last 4 of SSN
Last 4 digits of your social
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sex
Age
Children under 16 must be accompanied by a parent or legal guardian over the age of 18.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address

Confirmation Emailexample@example.com
Choose 1 or Both
Addit. Vaccines* Faculty/Staff only (optional)
Student Attest Insured or Uninsured
Faculty Attest Insured or Uninsured
Name of Health Insurance Plan
Member ID
Screening Questions
Are you/the patient sick today?
Are you/the patient pregnant?
Have you/the patient received any vaccinations in the past 4 weeks?
Have you/the patient ever fainted after receiving a vaccine or had a serious reaction to a vaccine or vaccine component?
Do you/the patient have cancer, leukemia, HIV/AIDS, or any other immune system conditions?
In the past year, have you/the patient received immune (gamma) globulin, blood/blood products, or an antiviral drug?
Consent
I have read, or have had read to me, the written information regarding the vaccine(s) being administered. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) being administered and have received or reviewed a copy of a current Vaccine Information Sheet. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Asthenis, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). I certify that I am at least 18 years old and hereby give my consent to Asthenis to administer the vaccine(s). If under 18 years old signature by parent or guardian is required. I agree to wait near the vaccination location for approximately 15 minutes for observation.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Covid/Flu Vaccination Registration/Consent

Screening Questions