I understand that if my insurance is different from that of my child, I must provide my insurance during the appointment or I will be responsible for my flu vaccine at the time of service.
CONSENT FOR VACCINATION: I have read, or have had explained to me, the Vaccine Information Statement for the vaccine (www.OCPH.info I havehadachanceto ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine requested and ask that the Flu vaccine be given to the person named above for whom I am authorized to make this request. I understand that a record of this immunization may be shared through the Wisconsin Immunization Registry (WIR) and with other health care providers directly involved with the vaccinated person's care. A copy of this consent form is as valid as the original.