FLU SHOT CONSENT FORM
Office Use Only:
Lot #:
Exp. Date:
Manufacture:
VS: (T)
(P)
(O2 sat)
Nurse Initials:
Dear Parent/Guardian,
The Healthy Kids Clinic will have influenza (flu) vaccinations available to students for the
____________ County schools during the months of August/September/October who have
signed their Healthy Kids Clinic consent forms and return them to the school. Please sign
below if you give permission for your child to receive the flu vaccine on the day our Provider and
nurse visit your child’s school. Also please indicate the type of vaccine you would like your child
to receive (injection or mist). Please note, the Center for disease Control (CDC) recommends
that children 6 months and older receive the Influenza vaccine.
Student Name:
School Name:
Homeroom:
Birthdate:
Allergies:
Parent/Guardian Name (Printed):
Parent/Guardian Signature:
Is the Child in Foster Care? __ YES __NO If Yes, Name of Social Worker:________________
Type of FLU VACCINE requested (please initial by vaccine):
___________ FLU INJECTION


___________ FLU MIST
The FLU MIST is an intranasal live virus and is not indicated for individuals with severe
allergies, allergies to EGGS/GELATIN/ANTIBIOTICS, respiratory diseases, history of
Guillain-Barre Syndrome, and any long-term health problems and/or weakened immune
system. This includes ASHTMA or any wheezing within the last 14 days, individuals on
aspirin, anticipated close contact with someone who has weakened immune system, and
receipt of any other vaccines in the past 4 weeks. These individuals should not receive
the flu mist.
The FLU INJECTION is given in the muscle and not indicated for individuals with severe
allergies, allergies to EGGS/GELATIN/ANTIBIOTICS, and history of Guillain-Barre
Syndrome.
Has your child ever received a Flu vaccine in the past? If the answer is yes, how many doses
(clinic or pharmacy name)?
____Yes ___No
Number of Doses ________ Where Given? ______________________
Did they receive a dose of flu vaccine in 2014-2015?
____ Yes ____ No
COMPLETE BOTH SIDES OF THIS FORM
Cumberland Family Medical Center, Inc. ● P.O. Box 2399 ● 404 Steve Drive ● Russell Springs, KY 42642
Toll Free: (800) 435-0900
Patient’s Last Name:
PATIENT INFORMATION
Please complete the following information about your child:
First:
Middle: Date of Birth: Social Security Number:
Mother’s First and Last Name:
Father’s First and Last
Name:
Child’s Last Name
at Birth:
Street Address:
Who is legal guardian?
(if foster child, list
social worker)
P.O. Box:
City:
State:
ZIP Code:
Home Phone Number:
Cell Phone Number:
Employer Phone Number:
Emergency/Secondary Contact Name:
Emergency/Secondary
Contact Number:
Relationship to Child:
Race:
⎕
White
⎕
Black or
African American
⎕
Asian
⎕
Native American or
Alaskan Native
⎕ Hispanic or Latino
Ethnicity:
How many people live in your home?
Sex:
⎕M
⎕F
⎕
Native Hawaiian or
Pacific Islander
⎕ Not Hispanic or Latino
What is your annual household income?
MEDICAL INSURANCE INFORMATION
If you have a Medicaid card, KCHIP card, or private insurance, please complete the information below.
Insurance Company Name:
Insurance Company Address: Insurance Company Phone Number:
Medical Card Number/ID/Policy Number:
Whose name is on the policy?
Group Number:
Policy Holder’s Date of Birth:
Relationship to Patient:
Cumberland Family Medical Center, Inc. ● P.O. Box 2399 ● 404 Steve Drive ● Russell Springs, KY 42642
Toll Free: (800) 435-0900