flu clinic satellite registration form by F4Eh05kX


									    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





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