Niles Sr. Center
PROVIDER: Corewell Health of Michigan
"I verify that I have been offered and received the
VIS about the immunization that I am receiving.
I have had a chance to ask questions which were
answered to my satisfaction" [ I asked about whether
the H1N1 strain and all expected Influenza A and Influenza
B strain effective version was to inoculate me ]
"I believe I understand the benefits and risks of the
vaccine that I am receiving and request that the
vaccine be given to me. I have been given an
opportunity to receive or renew the Corewell
Health HIPAA Notice of Privacy Practices, notice
of non-discrimination, surprise billing notice, notice
of Availability of language assistance service and
Auxiliary Aids and Services (NOA)."
FLULAVAL
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