Afluria IIV4 (.5ML PFS) 18 yrs. and older Administration Site Lot No. Date ________/________/2018 FluBlok RIIV4 (.5ML) 18 yrs. old & older Arm: L R _____________________ Signature Administering Nurse FluMist LAIV4 (.2ML) 2 49 yrs. old Thigh: L R – Exp. _________________ ___________________________ Fluzone HD IIV3-HD (.5ML PFS) 65 yrs.& older Nares 100 Saw Mill Road, Danbury, CT (203) 792-4120
Afluria IIV4 (.5ML PFS) 18 yrs. and older FluBlok RIIV4 (.5ML) 18 yrs. old & older FluMist LAIV4 (.2ML) 2 – 49 yrs. old Fluzone HD IIV3-HD (.5ML PFS) 65 yrs.& older Lot No. _____________________ Exp. _________________ Administration Site Arm: L R Thigh: L R Nares Date ________/________/2018 Signature Administering Nurse ___________________________ 100 Saw Mill Road, Danbury, CT (203) 792-4120
2018%20CT%20Consent%20Form%202018.docx