Flu Immunization Clinic
Please fill out this form to reserve a spot at the immunization clinic. If you have multiple people that need immunizations, please complete a separate form for each individual.
Clinic Location
*
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Immunizations Needed
*
Flu
COVID-19 Vaccine (Pfizer first, second or third dose)
Other
Please specify if other
COVID-19 Vaccine
If you selected COVID-19 vaccine above, please complete the registration form using the link at the submission verification page or the confirmation email after you submit this form. First, second or third dose Pfizer will be available.
What to Bring
Appointment
*
Please fill out the Patient Information Sheet, print it out and bring it the day of your appointment
IMPORTANT
If you are sick or not feeling well, please stay home. Please arrive at your appointment time. Please maintain social distancing upon entering the immunization clinic and please remember to wear your face mask if you are not fully immunized with the COVID-19 vaccine.
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