CONSENT FOR FLU VACCINE- I GIVE CONSENT to the office of VILMA JUNIO, MD, PLLC and its staff for my child to be vaccinated with Influenza vaccine/s and have my child?s immunization records included in the New York State Immunization Registry. I consent to my child?s immunization information and identifying demographic information being placed in the New York Immunization Registry to assist in my child?s medical care and treatment. The immunization information will be released to the patient if over 18 years of age, the parent or legal guardian of minor, their insurance company, their school or licensed daycare, the local and state health department, or to a medical provider authorize to provide medical care for my child. I understand that I can withdraw from the registry at any time with notification to my child?s medical care provider.