• Vaccination Consent Form

    Vaccination Consent Form

    Flu/Other vaccines
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    Pick a Date
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    Pick a Date
  • Screening for Vaccine Eligibility

    The following questions will help us to know if you get the seasonal influenza vaccine. If you answer “NO” to all of the following questions, you can get the influenza vaccine.  If you answer “YES” to one or more of the following questions, we will discuss your options for the flu shot. 
  • Please mark YES or NO for each question. 

  • Vaccine Information Sheets

    1. Inactivated Flu Vaccine Injection: https://www.immunize.org/vis/flu_inactive.pdf

    2. Live Nasal Mist: https://www.immunize.org/vis/flu_live.pdf

    3. All other vaccinations: https://www.cdc.gov/vaccines/hcp/vis/current-vis.html

     

  • Consent for Vaccination

    I have read the most current Vaccine Information Statement published by the CDC for the seasonal influenza vaccine or other vaccine I am receiving today and understand the risks and benefits. I give consent for PRACTICE to administer the flu vaccine or other vaccine I have chosen today.   I understand Dr. Risa Davidson may not be my PCP therefore any questions must be directed toward my own primary care physician.
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