DOCUMENTATION OF FLU VACCINE
DOCUMENTATION OF FLU VACCINE
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
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