Massachusetts Department of Developmental Services H1N1 “Swine Flu” Clinic Registration Form Please type or print clearly and legibly: Select clinic location: CSI ARC of NBC Sunshine Village HRU Agency Name: ___________________________________________________ Fax: ____________________________________________________________ Agency Contact Person: ____________________________________________ Telephone: _______________________________________________________ No one will receive vaccine without a signed consent form. BRING WITH YOU. Do not fax in with registration! Staff and/ or Individuals/ Guardians should have reviewed the vaccine information sheet and signed the consent form prior to arrival at the clinic. See attached clinic schedule and fax #s: An appointment is required. Please indicate below the date, time interval and location that you would prefer. Time intervals for appointments are listed on the attached schedule. (This document can be used to schedule several people at one clinic site, including staff) Fax or email this document to the appropriate clinic site (see attached clinic schedule for fax #s/email addresses) If there are no appointments available for your chosen time interval, you will be notified to choose another time. Due to the uncertainty regarding the availability of vaccine, please call 617-624-7792 twenty- four hours before the scheduled clinic and listen to the recording to confirm that the clinic is being held. Staff /Individual’s Name Specify Clinic Date and Time Interval 1. 2. 3. 4. 5.
Pages to are hidden for
"flu clinic satellite registration form"Please download to view full document