Vaccine Consent Form Flu Vaccine
Patient Name
Patient Date of Birth:
Phone Number
Address
School your child attends
Coal City Elementary
Fayetteville PK-8
Independence High School
Independence Middle School
New River Intermediate
New River Primary
Nicholas County High School
Oak Hill High School
Oak Hill Middle School
Summersville Middle School
Valley Pk-8
Not Listed
Child's Homeroom Teacher:
Child's Grade:
Check the vaccine to be administered below. Please review the Vaccine Information Statement here for
Influenza flu
Vaccine
,
Influenza (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.
Please select your child's insurance:
Medicaid/CHIP
Private Insurance
No Insurance
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.
Parent/Guardian Name
Parent/Guardian Signature
Clear
Patient Date of Birth:
Date
04
/
01
/
2025
Submit
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