Influenza Vaccine Intake

Please fill out the information below to complete your booking.

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Name of Person Getting Vaccinated(Required)

First Last

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Date of Birth of Person Getting Vaccinated(Required)

Name of Parent or Guardian if Person Getting Vaccinated is Under the age of 18.

First Last

Insurance Type(Required)

If you have a Medicare card, choose Medicare, even if you have another type of insurance.

Medicare

Medicaid (ForwardHealth) Number

Private Rx Insurance

No Insurance

Medicare Number(Required)

From Your Red White & Blue Card

Medicaid Forward Health Number(Required)

Insurance Name

Member ID Number(Required)

BIN Number(Required)

PCN Number

Rx Group Number

Driver's License Number(Required)