VIS and Consent Forms

Please note that completed forms must be faxed to Hudson Regional LTC Pharmacy at (845) 402-7039 at least 48 hours prior to the clinic.

Please follow the links below for the appropriate forms to be completed:

Vaccine Information Sheet:

Influenza: http://www.cdc.gov/vaccines/hcp/vis/vis-statements/flu.html

Pneumococcal: http://www.cdc.gov/vaccines/hcp/vis/vis-statements/ppv.html

Form Type

Description

Link

Agency Employee

Immunization Agency Employee

pdf

Resident with capacity

Immunization Resident with Capacity

PDF

Resident with guardian

Immunization Resident with Guardian

PDF

Resident with agency as guardian

Immunization Resident Agency is Guardian

PDF

 

Hudson Regional
LTC Pharmacy

280 Rte 211 E, Suite 112
Middletown, NY 10940

 

Tel: 845 341-2700

Fax: 845 341-2715

 

Mailing Address:

280 Rte 211 E, Suite 112
Middletown, NY 10940

 

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