Client's Name(Required)
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Client is(Required)
Client (check one)(Required)

Health Questions

Does the client have asthma or had wheezing in the last 12 months?(Required)
Is the client allergic to eggs?(Required)
Has the client ever had Guillain-Barre syndrome?(Required)
Is there anyone in the client's household who has a poor immune system?(Required)
Has the client ever had a flu shot before?(Required)
*If the client is less than 9 years old and never had a flu vaccine, 2 doses are needed one month apart.
Has the client ever had a bad reaction to a flu shot?(Required)
VIS Acknowledgement
For Child & Family Medical Clinic Visits: 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 of Southeastern CT, Inc. for services provided. I understand and acknowledge that I have read and understand this consent.
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