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Child and Family Agency

Child and Family Agency

Strong | Safe | Supported

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Forms – CBC Flu Vaccine


Flu Vaccine at the Community Bridge Clinic

Patient's Name(Required)
MM slash DD slash YYYY
Patient is(Required)
Parent/Guardian Name(Required)
Injection consent (child)(Required)
Injection consent (self)(Required)
Patient has (check one)(Required)

Health Questions

Is patient sick and/or have a fever?(Required)
Is patient allergic to eggs?(Required)
Has patient ever had Guillain-Barre syndrome?(Required)
Has patient ever had a flu shot before?(Required)
*If patient is less than 9 years old and never had a flu vaccine, 2 doses are needed a month apart.
Has patient ever had a bad reaction to a flu shot?(Required)
Click here to review the Influenza (Flu) Vaccine (Live, Intranasal) information statement.
Click here to review the Influenza (Flu) Vaccine (Inactivated or Recombinant) information statement.
VIS Acknowledgement
I give permission for my insurance to be billed at time of visit. I understand that a sliding scale will be available for those without insurance. I authorize the release of any medical information necessary to process my claim. I also authorize payment of health benefits to Child & Family Agency for services provided. I understand and acknowledge that I have read and understand this consent.
MM slash DD slash YYYY
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