Get Consent Form for Seasonal Influenza Vaccine
of influenza vaccine with a healthcare provider of my choice before coming here today. I have had a chance to ask questions which were answered to my satisfaction. I understand the benefits and risks of influenza vaccine and request that the vaccine be given to me. Please print clearly: Each field is required. Name: ________________________________________________ 3/4 ID or Last 4 SSN: _________________ (FIRST) (MIDDLE) (LAST) Birthday____/____/____ Vaccine is for (circle one): Student Physic.
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