• Influenza (Flu) Vaccine Consent Form

    Call the pharmacy with any questions (937) 610-3051
  •  - -
    Pick a Date
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Please answer the following questions.

  • For Medicare Recipients: I authorize the release of any medical or other information necessary to process this claim, I also request payment of government benefits either to myself or to the party who accepts assignment.

  • Clear
  • Should be Empty: