Springfield Flu Appointment & Consent Form

Signatures
I understand the benefits and risks of the vaccination(s) as described in the Vaccine Information Statement (VIS), a copy of which was provided with thisConsent and Release. I request the vaccine(s) be given to me or to the person named below, a minor for whom I represent that I am authorized to signthis Consent and Release.
I have received a copy of the notice of Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in whichmy health information may be used or disclosed by Springfield Pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.
Signature of Person to Receive Vaccine & VIS (or Parent/Guardian, if Recipient is 18 years or younger.)*

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By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.
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Flu Shot Appointment & Consent Form