DOCUMENTATION OF FLU VACCINE 20-21

Status

Status Not Completed Completed By/Date Completed By/Date
Your Information
Name Name * First Middle Last
Date of Birth Date of Birth * / MM / DD YYYY
Student ID Number ("A" Number)
Email *
Phone Phone * - ### - ### ####
Which Health Professions program do you attend? *

Which Health Professions program do you attend? Dental Hygiene Medical Laboratory Technology Nursing Phlebotomy Occupational Therapy Assistant Physical Therapist Assistant Radiologic Technologist
Date of Flu Vaccine (must be for 2020-2021 flu season) *
PLEASE UPLOAD DOCUMENTATION OF FLU VACCINE *

Attach Files
Draw your signature into the box below. (Note: If you are under 18 a parent/guardian must sign.)

Draw or Type

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Full Name

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Thank you for submitting your records.

A member of our staff will review and record the information and update your Clinical Clearance form within the next 3-5 business days.

The Wellness Center Staff