Forms Download

The forms below are listed by vaccine or service.

Provided is our HIPAA Privacy Policy about protecting your information and how the information may be used as regulated by Omnibus rule.

Print and fill out the Consent form and Authorization form prior to your visit.

Please review the VIS (vaccine information statement) for important information about the vaccine.

Vaccine/ServiceConsent Form Insurance Authorization formVIS
Flu 2020Flu Consent FormInsurance Authorization formFlu VIS
FluMist VIS
Mumps, Measles, and Rubella (MMR)MMR Consent FormInsurance Authorization formMMR VIS
Tetanus, Diphtheria, Pertussis (Tdap)Tdap Consent FormInsurance Authorization formTdap VIS
VaricellaVaricella Consent FormInsurance Authorization formVaricella VIS
Yellow FeverYellow Fever Consent FormYellow Fever VIS
Pneumococcal (23 and 13)Pneumococcal (23 and 13) Consent FormInsurance Authorization formPneumococcal 13 VIS
Pneumococcal 23 VIS
Tuberculosis Skin TestTuberculosis Skin Test Consent Form
Blood TestBlood Test Consent form


All forms are copyright of The Shot Nurse.