• FLU SHOT CONSENT FORM

    Student Clinic: September 2026

  • PATIENT INFORMATION

  • Date of Birth
     / /
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • SCREENING QUESTIONS

    Please select the correct option below.
  • Do you feel sick today?
  • Do you have an allergy to medications, foods or any vaccines?
  • Have you ever had a serious reaction or fainted after receiving any vaccination?
  • Have you ever had a seizure disorder, brain disorder, or Guillain-Barre Syndrome?

  • Influenza VIS

    Notice of Privacy Practices

  • ACKNOWLEDGEMENTS
  • INSURANCE INFORMATION
  • Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.

  •  
  • Should be Empty: