Influenza Immunization Consent Form: 2021 - 2022 Season

Consent Details: 

Thank you from the Atrium Health Teammate Health for receiving your vaccination for the 2021 influenza season. 

Before receiving the vaccine, you provided verbal consent to receive the vaccine and were able to ask questions about the vaccine. 

A copy of this vaccination is being sent to your Atrium Health medical record as a convenience and benefit to you and your Atrium Health provider to enrich your record of immunizations. 

Thank you for helping keep our teammates, patients and community safe. 

I have read the Seasonal Influenza Vaccine Information Sheet and had a chance to ask questions which were answered to my satisfaction. To the best of my knowledge, I do not have contraindications to the flu vaccine. I understand the benefits and risks of the vaccine and willingly receive the vaccination. 

Individual Information

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Immunization Information