Fast Flu

The FastFlu clinic will be on Saturday, November 2nd, 2019 from 8am - 12pm. For further information on the vaccines, please see the Vaccine Information Sheets found under Resources on our website.

Please correct the errors described below.

Family Information

Insurance Information

Medical Information

Consent Agreement

I have read the 2019-2020 Vaccine Information Sheet for the seasonal influenza vaccine. I understand the risks and benefits. I can give legal consent to Dr. Anne Georgulas and her staff for the Patient named in the Family Information section of this form. I give consent for Dr. Anne and her staff to vaccinate the Patient.

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