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Child and Family Agency

Child and Family Agency

Strong | Safe | Supported

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FLU VACCINE CONSENT FORM


Flu Shot Vaccine Consent Form 23-24

Patient's Name(Required)
MM slash DD slash YYYY
Patient is(Required)
Parent/Guardian Name(Required)
I want my child's school-based health center to give my child the flu vaccine(Required)
If you would like to be present for your child’s vaccine, please call 860-437-4550 to set an appointment. Otherwise, a time will be set to give the vaccine during the school day without a parent present.
Vaccines are available by appointment only. Please call 860-437-4550 to schedule an appointment with our Community Bridge Clinic located at 7 Vauxhall Street, New London, Connecticut.
Injection consent (child)(Required)
Injection consent (self)(Required)
Patient has (check one)(Required)

Health Questions

Does the patient have asthma or had wheezing in the last 12 months?(Required)
Is the patient allergic to eggs?(Required)
Has patient ever had Guillain-Barre syndrome?(Required)
Is there anyone in the patient's household who has a poor immune system?(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
For Community Bridge 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.
MM slash DD slash YYYY
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