10/22/2026 PENN-DELCO VACCINE CLINIC CONSENT FORM

Welcome to the online registration for Penn-Delco flu clinic provided by Springfield Pharmacy.

We will be visiting each school on Thursday October 22, 2026.

Thank You!
Please select who you are registering to receive the flu vaccine.
Staff vaccines will be given at Sun Valley High School at 3pm on Thursday October 22.
Please select which school.

ADULT VACCINE FORM PATIENT INFOMRATION
First Name
Last Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Gender
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State
Zip Code
Primary Care Doctor
Primary Care Doctor City, State
Please select vaccines to be received.

Insurance Information
By selecting "I do not authorize the pharmacy to bill my insurance," you are agreeing to pay cash for your vaccines at the time of administration. Cash price for Flu for people under the age of 64 is $50, Flu for people age 65 or older is $85. Please have cash with you at your appointment. Please sign below saying you agree and will have cash.
Insurance Company
Insurance ID Number
RX Group
RX BIN
PCN Number
Last 4 digits of your SSN
Medicare Part B
Upload a photo of your insurance card below

Cancelof

Privacy Policy

Click here to review Springfield Pharmacy's Privacy Policy

Vaccine Information Statements

Click here to review Influenza VIS information

Other Vaccine Information Statements can be found by clicking here
Acknowledgements

I understand the benefits and risks of the vaccination(s) as described in the Vaccine Information Sheet (VIS) or Emergency Use Authorization (EUA), a copy of which I was provided with this Consent & Release. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent & Release.
Signature
Date signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of person signing
Relationship to patient

VACCINE INFORMED CONSENT FORM (KIDS)
Patient First Name
Patient Last Name
Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Age
Gender
Parent/Guardian Email
example@example.com
Parent/Guardian Phone
Format: (000) 000-0000.
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State
Zip Code
Primary Care Doctor
Primary Care Doctor City, State
Emergency Contact Name
Emergency Contact Phone
Format: (000) 000-0000.
Vaccine to be received

INSURANCE INFORMATION
By selecting "I do not authorize the pharmacy to bill my insurance," you are agreeing to pay cash for your vaccines at the time of administration. Cash price for Flu for people under the age of 64 is $50. Please have cash with you at your appointment. Please sign below saying you agree and will have cash.
Insurance Company
Insurance ID Number
Rx Group
Rx BIN
Rx PCN
Upload a photo of your insurance card below

Cancelof

ACKNOWLEDGEMENTS
Privacy Policy

Click here to review Springfield Pharmacy's Privacy Policy

Vaccine Information Statements

Click here to review Influenza VIS information

Other Vaccine Information Statements can be found by clicking here
Acknowledgements

I understand the benefits and risks of the vaccination(s) as described in the Vaccine Information Sheet (VIS) or Emergency Use Authorization (EUA), a copy of which I was provided with this Consent & Release. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent & Release.

Parent/Guardian Consent and Authorization for Influenza (Flu) Vaccination
Springfield Pharmacy will be providing influenza (flu) vaccinations to students during the school day in coordination with the school's designated nurse. The flu vaccine helps protect against seasonal influenza and is recommended annually for all children 6 months and older by the CDC and the Advisory Committee on Immunization Practices (ACIP).
Students Grade
Students Teacher/Homeroom
I, the undersigned parent/guardian, hereby authorize Springfield Pharmacy and its licensed healthcare providers to administer the influenza (flu) vaccine to my child named above. (Please put your initials)
I Understand that:

1. The vaccine will be administered on school grounds in the presence of the school-designated nurse.

2. My child's participation is voluntary, and I may withdraw consent at any time before vaccination.

3. I have received and reviewed the current CDC Vaccine Information Statement (VIS) for the influenza vaccine. Click here to review Influenza VIS information

4. I understand that, as with any medical procedure, there may be risks and side effects, which have been explained.

5. I authorize Springfield Pharmacy to share relevant immunization information with the school nurse and appropriate public health authorities, as required by law, for reporting and recordkeeping.

6. I release and hold harmless Springfield Pharmacy, its employees, agents, and the school district from any liabilityarising from this vaccination, except in cases of willful misconduct or gross negligence.
Parent/Guardian Authorization

I have read and understood this consent form. I authorize Springfield Pharmacy to administer the influenza vaccine to my child at school under the supervision of the school nurse.
Signature of Parent/Guardian of Patient to receive the vaccines.
Date signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of person signing
Relationship to patient

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.
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ADULT VACCINE FORM PATIENT INFOMRATION

Questionnaire

VACCINE INFORMED CONSENT FORM (KIDS)

Questionnaire

ACKNOWLEDGEMENTS