In order to receive the flu vaccine, the law requires you to first fill out the Influenza Vaccination Consent form.

There are two version of the consent form, one for children ages 9-18 years and one for adults. Both versions can be downloaded from our site by clicking on the links below.

If you plan to visit one of our flu clinics you may download, print, fill out and bring 3 copies of the consent form with you to the clinic. Please note that each form requires 2 signatures .

Bringing the ready form with you may allow us to better serve you by expediting your visit and allowing us extra time to answer any questions you may have about flu or the flu vaccine that you would be receiving.

Adult Consent Form (PDF)              Child Consent Form (PDF)

About Health Information Privacy
Flu Prevention Partners adheres to and follows all rules and regulations on Health Information Privacy set by the U.S. Department of Health and Human Services (HHS). Any and all information disclosed by you to us will be used only for successful delivery of our vaccination services to you and will be protected under the full extent of the law.

If you would like to find out more about your Health Information Privacy Rights, you can download a two-page brochure published by HHS by clicking here.

For additional information, please visit the HHS Health Information Privacy website at www.hhs.gov/ocr/hipaa.

Note: To view the consent forms you need the Adobe Acrobat Reader. If you do not have the Reader installed, you can get it by clicking here