Flu Vaccination

Vaccinated Outside of Beaumont - Non-Employee


First Name:		Last Name
Male	Female	Date of Birth:
Work Location
Volunteer Student JLL Non-Employed Physician Private NP/PA Other
Physicians, Please enter your DR Number. (ex:DR1234)

I already received the influenza vaccine at the following location.

	Physician Name/Other:
	Date:


	Documentation of the influenza vaccination must be provided to OHS by January 6th of each year for approval. OHS is located at 550 Stephenson Hwy, Suite 200, Troy, MI 48083. Fax: 248-733-7301