Non-Employee Vaccine Administration Consent Form

This form is meant for non-Atrium Health employees.

If you are vaccinating an Atrium Health teammate, please use this Vaccine Immunization Consent Form.

Consent Details: 

You provided verbal consent to receive vaccines and were able to ask questions about the vaccine.

Vaccine Information Sheets (Influenza) have been provided to you and you have had a chance to ask questions which were answered to your satisfaction. To the best of your knowledge, you have no contraindications to the vaccine(s). You understand the benefits and risks of vaccine(s).

Individual Information

Influenza Immunization Information

Last Updated on 09/28/2023