Influenza Vaccine Consent Form

I have read the information about the influenza vaccine. I have had the opportunity to ask questions which were answered to my satisfaction. I understand the benefits and risks of the vaccine and request that the vaccine be given to me or to the person named below for whom I am authorized to make the request. I authorize St Clair Pediatrics, LLC to submit documentation for payment of this service to my insurance carrier and I agree to pay St Clair Pediatrics, LLC in the event that this service is not a covered benefit on my insurance policy.


  • Date Format: MM slash DD slash YYYY
  • If no, please be advised that two doses administered at least one month apart are recommended for children < 9 years of age who are receiving influenza vaccine for the first time.

What Our Families Are Saying

Hollie H.

Dr. Garrison and his staff are just the best!!!! I could not ask for a better pediatrician for my son!! I would highly recommend them to anyone! 

Catrina H.

We just switched to them and I’m so glad we did! The office is beautiful and clean and everyone there is very friendly and helpful.

Karen R.

As stressful as it can be to bring your sick child into the pediatrician’s office, the staff at St. Clair Pediatric’s always know how to provide a calm & comforting environment! The care provided by their staff is nothing short of spectacular.