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For US use onlyUniversity of Rochester | University Health ServiceINACTIVATED INFLUENZA VACCINATION CONSENT FOR 201920, Quadrivalent Please Print: Complete all information. Name: ___ Birthdate: ___
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Obtain a copy of the flu vaccine consent form.
02
Fill out the patient's personal information such as name, date of birth, and contact information.
03
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04
Sign and date the form where indicated to consent to receiving the flu vaccine.
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Anyone who wishes to receive the flu vaccine should fill out the flu vaccine consent form.
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It is a form required to consent to receiving a flu vaccine in November.
Individuals who wish to receive the flu vaccine in November are required to file this form.
The form must be completed with personal information and signed to indicate consent for receiving the flu vaccine.
The purpose is to obtain consent from individuals for receiving the flu vaccine in November.
Personal information, medical history, and consent for receiving the flu vaccine must be reported on the form.
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