I authorize the release of any information concerning my or my child’s health care, advice and treatment provided for the purpose of evaluating and administrating claims for insurance benefits. I also hereby authorize payment of insurance benefits otherwise payable to me directly to InClinic Rx, Eastern Carolina Medical Center Pharmacy, Avance Care Pharmacy, Hague Pharmacy at CHKD and other subsidiaries
I hereby consent to getting a vaccine given by InClinic Rx, Eastern Carolina Medical Center Pharmacy, Avance Care Pharmacy, Hague Pharmacy at CHKD and other subsidiaries
I have read the vaccine information statement and have had a chance to ask questions that were answered to my satisfaction. I understand the risks and benefits of the influenza vaccine. I understand that I will be asked to stay up to 20 minutes after I receive my flu shot. I ask that the influenza vaccine be given to me.
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FLU - VACCINE INFORMATION STATEMENT