• Lea County State Bank Influenza Informed Consent Form

    2026 - 2027

  • Personal Information

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

  • Flu Vaccine Declination

    Please fill out if you have received the flu vaccine at another facility
  • Did you receive a flu vaccine for the 2026-2027 season at another facility?*

  • Health & Safety Considerations

  • The influenza vaccine should not be taken by certain individuals. 

    If you answer yes by checking any of the following contraindications, the vaccine will not be administered until you have received a physician's approval.

  • Do you have allergies to medications, food, a vaccine component, or latex? Such as: neomycin, eggs, gelatin, MSG?*
  • Contraindication. Please check all that apply*
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