Vaccine Consent Form Flu Vaccine 

Please make note of the following:
·    If you sign and return this consent and decide to take your child elsewhere to get the flu vaccine, please call and let us know so they do not get an additional vaccine.
·    On the day your child receives their flu vaccine, they will be given a vaccine information sheet to take home.
·    If you are unsure if your child had their flu vaccine, please call the health center to confirm.
·    It will take several weeks to do all the vaccines but we will work as quickly as we can to get your child vaccinated.
·    
NRH partners with the WV Immunization Program and offers the flu vaccine to children who do not have insurance or whose insurance does not cover vaccines.  Please mark your insurance type below.
I have read the Vaccine Information Statement about the disease and vaccine. I understand the benefits and risks of the vaccine.  By signing below, I request the vaccine selected be given to the person named on this consent who I am authorized to sign for. I understand NRHA may release immunization records to other medical or school personnel on as as needed basis with the information being treated in a confidential manner.
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2025
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