Flu Shot Screen + Consent

For drive-up vaccines, please call 618-345-5437 when you arrive. Thanks!!!
Please read the flu vaccine info below:

Consent for Immunization
Patient Name *

First Name Last Name
Patient Date of Birth *

Month Day Year
I have been given a copy and have read, or have had explained to me, the information of the Vaccine Information Sheet (VIS) provided by the Centers for Disease Control (CDC) for each vaccine I/my child am to receive today.

I have had a chance to ask questions and they have been addressed to my satisfaction.

I understand the benefits and risks of each vaccine to be given.

I give my consent for each of the vaccines to be given to me/my child at this time.
Name of Parent/Guardian/ Adult Patient: *

First Name Last Name
Signature of Consent *

Clear
Date *

Month Day Year
Date