Flu Vaccine Consent Form
For CURRENT PATIENTS who have SUBMITTED A FLU VACCINE RESERVATION.

For the safety of our families, Little Silver Pediatrics & Family Medicine is offering:

* DRIVE-THU FLU VACCINE CLINICS 2022:  Sunday, October  9& 16.  Rain Date: Sun, Oct 23, 2022.

If you have submitted a flu vaccine reservation, to receive a flu clinic appointment date and time, please complete and submit this CONSENT FORM.  You must submit one consent form for each family member, including minor children. Thank you. fluclinic@LittleSilverMedicine.com
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Email *
Primary CELL PHONE NUMBER *
Please type Primary Cell Phone. 10-digit number without spaces, periods or dashes. For example: 7327415600
Alternate CELL PHONE NUMBER for notification
Please type your alternate cell phone for appointment confirmation
NO Co-Pay with your health insurance. Self-pay flu vaccine is $39
* SELF-PAY - must be paid prior to your appointment date. Please call office 24 hours before you visit.
* No flu shot without a reservation
* No pets allowed in the car
Health Insurance Company [Name] *
Member ID *
PATIENT LAST NAME *
PATIENT FIRST NAME *
PARENT/GUARDIAN FULL NAME [if patient is minor child]
PATIENT DATE OF BIRTH *
MM
/
DD
/
YYYY
PATIENT GENDER *
Do you/patient have a serious allergy to eggs *
Have you/patient had a serious reaction to a flu shot? *
For adult females:  Are you/patient pregnant? *
During the last 14 days, have you/patient had a fever? *
During the last 14 days, did you/patient have any COVID-19 symptoms - cough, shortness of breath, diarrhea or altered taste or smell? *
Have you/patient been diagnosed with COVID-19 *
If you answered YES to one or more of the above questions, you should discuss your options with your primary care physician before scheduling a flu shot.
Select a date for your flu clinic appointment.  Rain date for both is Sunday, October 24th. *
Required
Recommendations | 2022-2023 Flu Season & Vaccine
Consent & Permission to Release Information
I have read the 2021 Influenza recommendations  and Vaccine Information Statement published by the US Centers for Disease Control and Prevention for the Influenza vaccine, had my questions answered, and understand the risk and benefits.  I give consent to Little Silver Medicine (administrator) and its staff to be vaccinated with the 2021-2022 Influenza vaccine (inactivated, preservative-free). I have read the notice for consent to the Use and Disclosure of Health Information for Treatment, Payment or Healthcare Operations and give consent for release of data from the vaccination record for reporting to the CDC, administrative purposes, and, for community health improvement. -- (FVCF2021b)

By typing my name below, I give my consent. *
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