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Influenza Vaccination Consent Form 2021

Influenza Vaccination Consent Form 2021

Thank you for your interest in our Flu Clinic. Please fill out this consent form prior to attending your flu vaccine appointment. One form per patient.

HIPAA

Compliance

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    If you answered YES to having an Egg Allergy, please call your SCC Coordinator at 714-965-2558, as we have a VERY LIMITED SUPPLY of the egg-free influenza vaccine. You may not be able to receive a vaccine on 9/18 and will be scheduled for a later date.

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    Your signature once again confirms that you have received, read, and understood the Vaccine Information Sheet for the indicated vaccine, and give your consent for its administration.
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    Your signature once again confirms that you have received, read, and understood the Vaccine Information Sheet for the indicated vaccine, and give your consent for its administration.
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