Parent Vaccine Information
Please fill out a separate form for each parent or caregiver (limit 4) planning to receive the flu and/or COVID vaccine at Allegro during our 2026 Drive-Thru Clinics. Current Allegro patients and parents/caregivers who previously registered or received a flu shot at Allegro do not need to fill out a form.
Parent/Caregiver Name:
*
First Name
Last Name
Parent/Caregiver Gender:
*
Female
Male
Transgender Male / Female-to-Male
Transgender Female / Male-to-Female
Genderqueer; Neither exclusively Male nor Female
Declined
Other
Parent/Caregiver Date of Birth:
*
/
Month
/
Day
Year
Please note that we will NOT have high dose flu vaccine for those 65 years and older available at our drive-thru clinics.
Parent/Caregiver Address Line 1:
*
Address Line 2:
City:
*
State:
*
Zip:
*
Parent/Caregiver Mobile Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Caregiver Home Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Phone
*
Please Select
Mobile
Home
Parent/Caregiver Email:
*
example@example.com
Race:
White
Black or African American
Asian
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
Decline to answer
Parent/Caregiver Race:
*
White
Black or African American
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Decline to Answer
Parent/Caregiver Ethnicity:
*
Latino/Hispanic
Not Hispanic or Latino
Other
Decline to Answer
Children Seen at Allegro
Established Patient Full Name:
*
First Name
Last Name
Established Patient Date of Birth:
*
/
Month
/
Day
Year
Date
Additional Patient
Established Patient Full Name:
First Name
Last Name
Established Patient Date of Birth:
/
Month
/
Day
Year
Date
Additional Patient
Established Patient Full Name:
First Name
Last Name
Established Patient Date of Birth:
/
Month
/
Day
Year
Date
Additional Patient
Established Patient Full Name:
First Name
Last Name
Established Patient Date of Birth:
/
Month
/
Day
Year
Date
Additional Patient
Established Patient Full Name:
First Name
Last Name
Established Patient Date of Birth:
/
Month
/
Day
Year
Date
Additional Patient
Established Patient Full Name:
First Name
Last Name
Established Patient Date of Birth:
/
Month
/
Day
Year
Date
Additional Patient
Established Patient Full Name:
First Name
Last Name
Established Patient Date of Birth:
/
Month
/
Day
Year
Date
Submit
Should be Empty: