Signatures
I have have given my consent to recieve the Fluzone Influenza Vaccine. I understand the benifits and risks of the vaccine being administered and authorize the administration of the vaccine to me or to the person named above for whom I am authorized to make this decision.
ATTENTION: Any child under 3 years must have a prescription for each dose of a vaccine. The parent or guardian of the child must contact their medical provider who must send a prescription into the pharmacy prior to each dose.