• INFLUENZA VACCINE ADMINISTRATION RECORD

  • Your pharmacist will keep this record on file

    I have read or have had explained to me written information about the vaccine listed below. I have had an opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine being administered and authorize the administration of the vaccine to me or to the person named below for whom I am authorized to make this decision. I understand that this information will be forwarded to my physician or primary care provider.”

  • as on Medicare or Insurance card)

  •  /  /
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  • as on Medicare Card, including letters)

  •  /  /
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  • Signature of person to receive the vaccine or person authorized to make the request (parent or guardian) and release this information to the patient’s physician or primary care provider:

  • Clear
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  • Should be Empty: