FLU SHOT FORM

(We are required to inform you of our privacy practices for the information we collect and keep about you). I certify that the information I have provided is true and accurate. I consent to the services being requested. I have been given a copy and have read, or have had explained to me, the information in the important Vaccine Information Statement. I have had a chance to ask questions, which were answered to my satisfaction. I believe I understand the benefits and the risks of the vaccine and request that the vaccine indicated be given to the person named above for whom I am authorized to make this request. I agree that this information may be shared with schools, day care centers, health care providers, or others when deemed medically necessary, as well as the Utah Statewide Immunization Information System (USIIS). I agree to provide written notice if I do not want my information shared with USIIS. I hereby release Southwest Utah Public Health Department (SWUPHD) and its employees from all claims arising from such immunizations. I understand that billing of medical insurance does not guarantee payment and that I am responsible for any unpaid balance. I have reviewed SWUPHD’s Notice of Privacy Practices and had the opportunity to ask questions regarding my information.