Faculty Vaccine Consent

Faculty Vaccine Consent Form
Patient Details
Full, Legal Name (First Name, Middle Initial, Last Name) *

First Name Middle Initial Last Name
Birth Date *

Month Day Year
Age *
Sex *
Email Address *
example@example.com
Address *

Street Address

Street Address Line 2

City

Postal / Zip Code
Primary Phone # *
Secondary Phone #
School Details
Name of School *
School Campus
Insurance Details

The current health care laws require us to bill your insurance company for the vaccine. There will be no out of pocket expense for those insured.
Insurance Company *
Member ID *
Group # *
Policy Holder's Name *
Policy Holder's Date of Birth *

Month Day Year
Vaccinations

IF YOU HAVE ANY HEALTH QUESTIONS, PLEASE CONTACT YOUR PRIMARY CARE PHYSICIAN OR CALL AURORA CONCEPTS AT 936-598-3296 TO SPEAK TO A NURSE.
Vaccine(s) to be given *

FLU PCV13 PCV23 Tdap Shingrix Hep A Hep B B12 Lipo-C Labs
Signature
I acknowledge that Aurora Concepts provided me and I have been afforded the opportunity to read the Notice of Privacy Practices and CDC Vaccine Information Statement for the vaccine(s) indicated on their website: www.auroraconcepts.net under the 'Patient Resources' tab.
Signer's Name *
Signature *

Use your mouse or finger to sign Clear
Date *

Month Day Year
Should be Empty:

Faculty Vaccine Consent Form