Healthy Reminder

Healthy Reminder Flu Shots on October 20th 2:30 – 3:30 at Era I.S.D

4 year olds and up

If you would like for your child to receive a Flu shot at school, please sign and return this form by October 14th with money (cash or check) to the school office. Your insurance can be used as payment if your insurance pays 100% for the flu shot and is a PPO. You must send a copy of your insurance card (front and back) so that your insurance can be filed. You must sign the form in order to give permission for your student to receive the flu shot without you being here.

Students who have turned in forms will be called out to get the flu shot. You can check with the office or me before the 20th to make sure your student has turned in the forms. If you have questions, you can email me at [email protected]

______Yes, I want my child to receive the Flu vaccine offered at Era School, Oct. 20th by North Texas Family Medicine.

______No, I do not wish for my child to receive the Flu vaccine

Note: Parents do not need to be present when child receives shots, if the proper paperwork is filled out ahead of time

Please complete the next section of the form and return, we will pull your child from class and give shot and return them to class afterwards. +++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ +++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ ++

North Texas Family Medicine 1340 North HWY 377 Ste 110, Pilot Point Texas 76258, 940-686-0860

Date ______Student Name ______DOB ______

Address______Phone # ______

Payment: Trivalent flu shot: $ 25.00 Cash ______$ 25.00 Check ______Quadrivalent flu shot: $35.00 cash_____ Check_____ (Payable to NTFM) Insurance Card copy____ Medicare Card ______

Are you allergic to chicken or eggs? YES NO

Do you have a history of Gullian-Barre Syndrome? YES NO

Teachers Name: ______Grade______

______Parent Signature Date

Office Use only

4 yrs. and up / Adult Brand: _FluVirin______lot # _1619101______Exp ______042017______Injection Site: Right Deltoid Left Deltoid Nurse ______