• Wichita USD 259 Flu Vaccine Consent Form

    Damm Pharmacy will be at Wichita USD on 12/01/22 from 4-6pm to administer flu vaccines. Please fill out all information to the best of your ability. If you have any questions we will be happy to answer them on the date of vaccination. **If filling out this form within a few hours of the clinic, you may be asked to partially fill out a paper form on-site as we will not have a way to print them during the clinic.
  • Patient Information

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  • Patient Screening Questions

  • Information on Flu vaccines can be found here:

    Flu: https://www.cdc.gov/vaccines/hcp/vis/vis-statements/flu.pdf

     

     

     

  • If yes, to any allergies please list the allergy.

  • If you have received a vaccine in the last 30 days, please list the vaccine.

  • Insurance Information

    Please fill out to the best of your ability and/or upload an image of your insurance card if possible.
  • If Commercial Insurance:
  • If Uninsured please list the following:
  • If Medicaid:
  • If Medicare:
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  • I understand the benefits and risks of the flu vaccine as described in the vaccine information sheet, a copy of which I was provided with this consent and release. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this consent and release.

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