• Vaccine Clinic Registration Form

  • What vaccine(s) are you interested in receiving?
  • Date of Birth*
     - -
  • Gender*
  • Format: (000) 000-0000.
  • Race*
  • Which arm do you prefer for the vaccine?*

  • Influenza Vaccine Information Statement

  • Click HERE to review the vaccine information statement for the influenza vaccine

  • Health and Medical History

  • Are you sick or experiencing any signs of COVID-19 (e.g. cough, fever, loss of taste/smell?*
  • Have you had a serious reaction to the flu vaccine requiring medical help?*
  • Have you received a live vaccine in the past 30 days (e.g. MMR, chickenpox, Rotavirus)? If YES, it is recommended to space live vaccines by >4 weeks for full efficacy.*
  • Do you have a severe allergy to eggs?*
  • Do you have a severe allergy to Neomycin or Thimerosal (preservative found in contact lense solution)?*
  • Do you have any of the following chronic health conditions?*
    • Cancer
    • Chronic Kidney Disease
    • COPD (Chronic Obstructive pulmonary disease)
    • Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies
    • Immunocompromised state (weakened immune system) from solid organ transplant or HIV
    • Obesity (body mass index [BMI] of 30 kg/m2 or higher but < 40 kg/m2)
    • Severe Obesity (BMT >= 40 kg/m2)
    • Sickle Cell disease
    • Smoking
    • Type 2 diabetes mellitus
  • Have you ever had Guillain-Barre syndrome (GBS) or a persistent neurological illness?*
  • Are you pregnant or think you may be pregnant?*
  • Please select a time for your appointment
    • Required Documentation for Vaccination Appointments 

    • You will need to show proof of identity at your appointment. Examples include:

      • Driver's license
      • California ID card or REAL ID card (from the DMV)
      • Military ID
      • Passport 

       

    • Should be Empty: