Flu Form

Vaccine Administration Consent Form

I agree that the person named below will receive the vaccine indicated and that this person will have a vaccine administered by injection to prevent infectious disease. I received a current copy of the Vaccine Information Statement for this vaccine and have had the opportunity to ask questions concerning the benefits and risk of the vaccine and the diseases they prevent. I freely and voluntarily authorize the administration of the vaccines to me or the person named below for whom I am authorized to make this decision. 

Please Answer the Following Questions:

Phone Number:

Fax Number


Store Hours

Monday – Friday  (8:30 AM – 7:30 PM)
Saturday (9:00 AM – 4:00 PM)

Sunday (CLOSED)


Randol Mill Pharmacy
1014 N. Fielder Rd. Arlington, TX 76012

Thank You for your Transfer