FLU SHOT ONLINE FORM

You can always press Enter⏎ to continue

Flu Shot Questionnaire Form

Free with most insurances

17Questions

1
Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.MM/DD/YYYY
3
Email* This field is required.For appointment confirmation & directions.
example@example.com
4
Are you sick today?* This field is required.
YESNO
5
Do you have allergies to medications, food, a vaccine component, or latex?* This field is required.If yes, the pharmacist will ask you in detail
YESNO
6
Have you ever had a serious reaction after receiving a vaccination?* This field is required.
YESNO
7
Do you have a long-term health problem with heart, lung, kidney, or metabolic disease (e.g., diabetes), asthma, a blood disorder, no spleen, complement component deficiency, a cochlear implant, or a spinal fluid leak? Are you on long-term aspirin therapy?* This field is required.
YESNO
8
Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?* This field is required.
YESNO
9
Do you have a parent, brother, or sister with an immune system problem?* This field is required.
YESNO
10
In the past 3 months, have you taken medications that affect your immune system, such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoidarthritis, Crohn’s disease, or psoriasis; or have you had radiation treatments?* This field is required.
YESNO
11
Have you had a seizure or a brain or other nervous system problem?* This field is required.
YESNO
12
During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?* This field is required.
YESNO
13
For women: Are you pregnant or is there a chance you could become pregnant during the next month* This field is required.If not applicable, please select No
YESNO
14
Have you received any vaccinations in the past 4 weeks?* This field is required.
YESNO
15
Please take a photo of a valid government identification* This field is required.Ex: Driver License, Military ID, Passport
16
Appointment* This field is required.
17
I hereby certify that the above statements are true and correct to the best of my knowledge
Clear
Should be Empty:

Question Label

1 of 17See AllGo Back

Save & Continue Later

Your form is saved successfully!

If you want to continue answering your form later, please enter the email address you would like to send the link to:

Please enter a valid email address.

Something went wrong while saving your answers. Please try again.

Email has been sent successfully.

Save your progress

OR

Already have an account? LOGIN

Skip Create an Account

Save your progress

Name

Email Address

Password

I agree to theTerms of ServiceandPrivacy Policy

Your form submission has been saved as a draft.

If you want to continue answering your form later, please enter the email address you would like to send the link to:

Save your progress

OR

Username or email

Password

Forgot Password?

Your form submission has been saved as a draft.

We’ve sent you an email with a link to complete your submission.