Consent Forms for
H1N1 Vaccine Clinics

Clinic Date
Saturday, June 12, 2010
11:00 a.m. - 2:00 p.m.

Boscov's at Cumberland Mall
Vineland, NJ 08360

Vineland Health Department
Public Health Nursing Div.
610 Montros Street, Suite 1
Vineland, NJU 08360

Every Monday & Wednesday
2-4 p.m.

Please complete Section 1, 2 and 3 of forms for each individual getting vaccine and bring it with you to speed up the clinic time.

(If possible, fill out forms online, if not possible please print clearly)

English Forms
Print Fill-In

Formularios en Español
Imprimir Llenar

PLEASE READ OUR NOTICE OF PRIVACY BEFORE COMING TO THE CLINIC. THANK YOU!

NOTICE OF PRIVACY
IN ENGLISH AND SPANISH