2009 - 2010 Flu Shot Vaccination Consent Form

Please enter your information to receive 2009 Influenze vaccine. This needs to be filled out for employees, spouses, children, etc.   First Name: *   Middle Initial: Last Name: *   Birthday: *   (mm/dd/yyyy)     Gender: * MF   Mailing Address 1: *   Mailing Address 2: City: *   State: *     Zip Code: *    Day Phone: Email:   Confirm Email:   Screening Date:  (mm/dd/yyyy)   Company Name: *   Classification: Employee Spouse Other  If "other", please specify:      Yes! I do wish to receive information via e-mail from Wake Forest University Baptist Medical Center about programs, classes and services.