• Influenza Vaccine
    Consent & Release Form
  • Section 1 of 3 - Recipient Information

    All 3 sections are required for each vaccine recipient. All information is protected under HIPAA privacy laws.
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  • PHYSICIAN (M.D) INFORMATION

    Please provide your Primary Care Physician's information

  • Section 2 of 3 - Insurance Information

    If you have medical coverage please provide the information below.
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  • If applicable on insurance card, please provide your:

    • Rx BIN Number
    • Rx PCN Number
    • Rx GROUP Number
  • Section 3 of 3 - Pre-Vaccination Questions

    Please answer the screening questions below so that we may take appropriate precautions when needed.
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