Forms download


    
This page provides you with forms and patient education materials that you need for flu vaccine, medication assistant training, CPR and immunization.  Please read each form carefully before signing.  If you have any questions regarding these forms or the contents herein, feel free to contact our main office at 301-460-6372.  You will need Acrobat Reader to view or print these forms in Portable Document Format (PDF). You should have Adobe Acrobat Reader version 5 or higher to view these documents.
   

Myclinic

Type/Size
Flu clinic contract (PDF, 109.5 KB)
Flu vaccine consent form (English), (Spanish) (PDF, 601 KB)
Flu vaccine information sheet (VIS) (English), (Spanish) (PDF, 801 KB)
Customer Receipt (PDF, 62 KB)
Clinic Schedule (PDF, 56 KB)
Flu Vaccine Reaction form (PDF, 275 KB)
Post-Service Flu Vaccine Information form (PDF, 466 KB)
Is it a Cold or the Flu? (PDF, 216 KB)
Is it a Flu Shot Fact or a Myth? (English), (Spanish) (PDF, 170 KB)
Three top reasons to get a Flu Shot! (PDF, 151 KB)
Medication Technician training  
Medication Technician Training Contract (PDF, 36.0 KB)
Medication Technician List (PDF, 6.5 KB)
Medication Technician Evaluation form (PDF, 406 KB)
Immunization  
Diphtheria, Tetanus and Pertussis (Vaccine Information Sheet (VIS) (PDF, 40 KB)
Haemophilus Influenzae Type b (Hib) (VIS) (PDF, 56 KB)
Hepatitis A - (VIS) (PDF, 79 KB)
Hepatitis B - (VIS) (PDF, 50 KB)
Hepatitis B - Consent Form (PDF, 34 KB)
Pneumonia - (VIS) (PDF, 43 KB)
Polio - (VIS) (PDF, 240 KB)
Japanese Encephalitis (VIS) (PDF, 224 KB)
Meningococcal (VIS) (PDF, 44.4 KB)
Measles, Mumps and Rubella (VIS) (PDF, 36.1 KB)
Rabies (VIS) (PDF, 60.1 KB)
Tetanus and Diphtheria (VIS) (PDF, 76.1 KB)
Tdap (VIS) (PDF, 45.8 KB)
Typhoid (VIS) (PDF, 61.2 KB)
Chickenpox (VIS) (PDF, 39.0 KB)
Yellow Fever (VIS) (PDF, 192.0 KB)
   

 

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