Utah - Tooele County Health Department
             
School Flu Vaccination Clinics
151 North Main Street - Tooele, UT 84074
Phone: (435) 277-2310
www.tooelehealth.org

Please send Consent Form form with your child.
ENGLISH CONSENT FORM
SPANISH CONSENT FORM
 

If you have insurance and the insurance policy is NOT one of the following OR your insurance does not cover the vaccine, the cost will be $30.00: Aetna, Altius, Blue Cross/Blue Shield, CHIP, Cigna, DMBA, Educators Mutual  Health Choice, Health U, Mailhandlers, Medicaid, Medicare, Molina, PEHP, Select Health, Tricare,  United Health.

 
Flu Shot:   $30.00   Quantity:   Item Subtotal:  
$0.00
Child's Name [1]
Name of School [1]
Grade [1]
Date of Birth [1]
Teacher's Name [1]

Child's Name

[2]
Name of School [2]
Grade [2]
Date of Birth [2]
Teacher's Name [2]

Child's Name

[3]
Name of School [3]
Grade [3]
Date of Birth [3]
Teacher's Name [3]

Child's Name

[4]
Name of School [4]
Grade [4]
Date of Birth [4]
Teacher's Name [4]

Child's Name

[5]
Name of School [5]
Grade [5]
Date of Birth [5]
Teacher's Name [5]

Child's Name

[6]
Name of School [6]
Grade [6]
Date of Birth [6]
Teacher's Name [6]

Child's Name

[7]
Name of School [7]
Grade [7]
Date of Birth [7]
Teacher's Name [7]

Child's Name

[8]
Name of School [8]
Grade [8]
Date of Birth [8]
Teacher's Name [8]

Child's Name

[9]
Name of School [9]
Grade [9]
Date of Birth [9]
Teacher's Name [9]

Child's Name

[10]
Name of School [10]
Grade [10]
Date of Birth [10]
Teacher's Name [10]

 
NO Insurance - 18 years of age and under
Flu Shot:   $   Item Subtotal:  
$0.00
Child's Name [1]
Name of School [1]
Grade [1]
Date of Birth [1]
Teacher's Name [1]

Child's Name

[2]
Name of School [2]
Grade [2]
Date of Birth [2]
Teacher's Name [2]

Child's Name

[3]
Name of School [3]
Grade [3]
Date of Birth [3]
Teacher's Name [3]

Child's Name

[4]
Name of School [4]
Grade [4]
Date of Birth [4]
Teacher's Name [4]

Child's Name

[5]
Name of School [5]
Grade [5]
Date of Birth [5]
Teacher's Name [5]

Child's Name

[6]
Name of School [6]
Grade [6]
Date of Birth [6]
Teacher's Name [6]

Child's Name

[7]
Name of School [7]
Grade [7]
Date of Birth [7]
Teacher's Name [7]

Child's Name

[8]
Name of School [8]
Grade [8]
Date of Birth [8]
Teacher's Name [8]

Child's Name

[9]
Name of School [9]
Grade [9]
Date of Birth [9]
Teacher's Name [9]

Child's Name

[10]
Name of School [10]
Grade [10]
Date of Birth [10]
Teacher's Name [10]
($15.00 or whatever you can afford)

 
NO Insurance - 19 years of age and older
Flu Shot:   $30.00   Quantity:   Item Subtotal:  
$0.00
Child's Name [1]
Name of School [1]
Grade [1]
Date of Birth [1]
Teacher's Name [1]

Child's Name

[2]
Name of School [2]
Grade [2]
Date of Birth [2]
Teacher's Name [2]

Child's Name

[3]
Name of School [3]
Grade [3]
Date of Birth [3]
Teacher's Name [3]

Child's Name

[4]
Name of School [4]
Grade [4]
Date of Birth [4]
Teacher's Name [4]

Child's Name

[5]
Name of School [5]
Grade [5]
Date of Birth [5]
Teacher's Name [5]

Child's Name

[6]
Name of School [6]
Grade [6]
Date of Birth [6]
Teacher's Name [6]

Child's Name

[7]
Name of School [7]
Grade [7]
Date of Birth [7]
Teacher's Name [7]

Child's Name

[8]
Name of School [8]
Grade [8]
Date of Birth [8]
Teacher's Name [8]

Child's Name

[9]
Name of School [9]
Grade [9]
Date of Birth [9]
Teacher's Name [9]

Child's Name

[10]
Name of School [10]
Grade [10]
Date of Birth [10]
Teacher's Name [10]
 
Total:
$0.00

Parent/Guardian Information
First Name: Last Name:
Address:
Address:
City: State/Province: ZIP/Postal Code:
Phone: Email:
Payment Information
Method of Payment:
Update name from Parent/Guardian Information
Name of Individual
on Checking Account:
Name of Individual
on Savings Account:
Name of Business
on Checking Account:
Bank Routing Number:
Bank Account Number:
Credit Card Number: (Type number or swipe with cursor in this empty field)
Expiration Date: /
Card ID (CVV2/CID) Number: What is the Card ID?
Cardholder Information (exactly as it appears on your statement)
  Update from Parent/Guardian Information
Cardholder's Name:
Billing ZIP/Postal Code:
 
Please be aware that card payments will be described as
TooeleUT 800-764-0844 Tooele UT

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