Please complete, submit and print this form, sign it and bring it with you.
Consent for Influenza Vaccine
Complete information about person to receive the vaccine.
Participant/Parental Informed Consent Signature:
By signing I have received and agreed to the following:
Please make a selection. I hereby release Lehigh Valley Health Network, its Hospitals, physicians, employees, agents, representatives, and assigns from any and all liability that may be associated with my (my child's) receipt of the flu vaccine.