Wanaque, MT · Passaic County
Informed Consent for Receipt of Influenza Vaccine
Wanaque residents complete this consent form to agree to receive an influenza vaccine and provide information for Medicare payment, if applicable.
What this form is
This form records a person's consent to receive an influenza vaccine from the Wanaque Health Department. It asks about health considerations, confirms the signer understands vaccine risks and benefits, and includes a release of liability. A separate section requests Medicare payment authorization and eligibility information for influenza vaccination.
Who needs it
People completing the form to receive an influenza vaccine from the Wanaque Health Department should provide the requested consent and personal information.
How to submit it
Submit it to the city department named on the form; check the city website for current contact details.
About notarization
This document is signed without a notary; the signer just signs and dates it.
How to submit this form
- 1
Download The Form
Download the influenza vaccine consent PDF.
- 2
Complete The Form
Read the statements, provide the requested information, and sign and date the form.
- 3
Gather Mentioned Materials
Review the attached influenza and vaccine information; the form says people taking steroids or chemotherapy should bring a doctor's order.
- 4
Submit To The City
Submit the completed form to the city department named on it; check the city website for current contact details.
Frequently asked questions
- Do I need a notary for the influenza vaccine consent form?
- No. The form has a signature and date line but no notary block; the signer just signs and dates it.
- How do I submit the influenza vaccine consent form?
- Submit it to the city department named on the form; check the city website for current contact details.
- What information does the form ask for?
- It asks for health-related consent statements, a signature, date, mailing address, phone number, birthdate, and Medicare eligibility information.