Faculty Vaccine Consent

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

First NameMiddle InitialLast Name
Birth Date*

MonthDayYear
Age*
Sex*
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

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*

MonthDayYear
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*

FLUPCV15PCV20PCV23TdapShingrixHep AHep BB12LipoLabs
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*

Clear
Use your mouse or finger to sign
Date*

MonthDayYear
Should be Empty:

Faculty Vaccine Consent Form