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Lassen Public Health Offering County-Wide Flu Vaccinations

Lassen Public Health Offering County-Wide Flu Vaccinations 2026

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60 votes

The document is a consent form for the Lassen County Public Health Department's Influenza Vaccination Clinic for the 2018-2019 season. It collects personal information, medical history, and vaccination status from individuals receiving the flu vaccine. The form also includes a HIPAA privacy statement outlining the protection of health information and its permissible uses in public health activities.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your personal information. Fill in your first name, last name, middle name, address, city, state, and zip code clearly.
Next, provide your date of birth by selecting the month, day, and year from the dropdown menus.
Indicate your gender by selecting either 'Male' or 'Female'. If applicable, answer whether you are pregnant or think you might be pregnant.
Respond to the questions regarding past flu vaccinations and any severe reactions to vaccines. This includes confirming if you've had a fever in the last 24 hours or received an MMRV vaccine in the last 30 days.
If using flu mist, indicate if anyone in your home is immune compromised.
Review the Influenza Vaccine Information Statement provided. Confirm that you understand the benefits and risks of the vaccine before signing and dating the form.

Start filling out your vaccination form online for free today!

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Versions	Form popularity	Fillable & printable
2021	4.4 Satisfied (43 Votes)
2020	4.7 Satisfied (30 Votes)
2018	4.4 Satisfied (60 Votes)
2017	4.9 Satisfied (21 Votes)

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