Drive-Thru Flu Vaccination Pre-registration

Flu Vaccination Event Registration

Register now to help eliminate long lines.
- If using health insurance, please have your insurance card handy while completing the form.
- Only patients themselves, parents, or guardians may complete this form.
- You will need to submit a form for each patient you are registering.
What would you like to do?*

Complete a new regisrationChange an existing registrationCancel a registration

Registration Cancellation
Change Appointment

Enter the appointment details that you already have, but wish to change.
Patient First Name*
Patient Last Name*
Patient Date of Birth*

MonthDayYear
Date
Phone Number*
Email
example@example.com
What date and time were you scheduled for?*
Please proceed with choosing a new date, time, and location on the next page.

Choose Preferred Date and Time
Please choose the location, date, and time you would like to change to.
Choose your date and location*
Please note: Both Health Fair dates are walk-in events.
This event will be a DRIVE THRU event. Please follow the signs when you arrive.
The online registration time for this event is closed, but you can still come for your flu shot on this date. You can complete your registration paperwork when you arrive.
These flu shots will be given as a part of our Amberwell community health fair!

Please enjoy some of the other activities while you are there! There will be displays and activities from many community organizations, health screenings, bouncy houses for kids, Touch-a Truck, giveaways, and more!
Flu shots on this date will be given INSIDE Amberwell Atchison, in the primary care area. Please follow the signs inside the building to the check in area.
Choose a time slot for Thursday October 24 at Amberwell Atchison.*
Date and Location
Chosen time slot:
Your Date and Location: {dateAnd}
Your Time: {chosenTime}

Patient First Name*
Patient Last Name*
Patient Date of Birth*

MonthDayYear
Date
Email
example@example.com
Phone Number*
Have you been a patient at any Amberwell location within the past 3 years?*

Yes, I have been a patient in the past 3 yearsI am a new patient, or it's been longer than 3 years since I have been a patient
What location do you usually visit for primary care?
Organization
Who is your primary care provider at Amberwell Atchison?*
Who is your primary care provider at Amberwell Horton Clinic?*
Who is your primary care provider at Amberwell Lansing Clinic?*
Who is your primary care provider at Amberwell Highland Clinic?*
Who is your primary care provider at Amberwell Troy Clinic?*
Who is your primary care provider at Amberwell Eighth Street Clinic?*
Who is your primary care provider at Amberwell Hiawatha?*
Provider:
Insurance type*
Insurance carrier*
New patient information*

I would like to complete online nowPlease call me to complete over the phone

New patient information

Please complete the following fields to register as a new patient.
SSN*
Sex*
Marital status*
Race*
Ethnicity*
Language
Religion
Religion
Employment Information
Employment status*
Employer Name
Employer Address
Person Responsible for Bill
Relationship*
Employment status
Employer Name
Employer Address
Insurance Information
Insurance type
Insurance carrier name
Policy holder
Policy number
Group number
Insured person information:
Employment status
Employer name
Employer address
Do you have secondary insurance?

noyes
Secondary Insurance
Policy holder
Policy number
Group number
Insured person information:
Employment status
Employer name
Employer address
Emergency Contact
Emergency contact name

First NameLast Name
Emergency contact phone
Relationship to patient

SpouseParent/guardianOther
Address

same address as patientdifferent address than patient
Address
I hereby authorize my provider to furnish my insurance company or its representative or permit my insurance company or its representative to review any information requested with respect to any illness or accident, medical history or copies of hospital and medical records. A photostatic copy of this authorization shall be considered as valid as the original. I hereby authorize payment directly to my provider for this illness or injury, of the provider’s benefits otherwise payable to me, but not to exceed my indebtedness to said provider. I agree to pay the provider for all my charges whether or not covered by this assignment. The responsible party hereby agrees that the provider’s office or the party responsible for the billing of these services may check credit with any source to obtain credit information. I authorize any holder of medical information about me to release any information needed to determine these benefits payable for related services. This release may include information which may be considered a communicable or venereal disease which may include, but are not limited to diseases such as hepatitis, syphilis, gonorrhea and the human immunodeficiency virus, also known as acquired immune deficiency syndrome (AIDS). I understand all of the above and hereby state that the information is correct to the best of my knowledge. My signature indicates that I have read the above and grant the request of authorizations. I have been notified that I may receive services from the Nurse Practitioner or Physician Assistant at this location.
Patient or Authorized Person’s Signature*

Clear

Influenza Vaccination Consent

Please complete the following questions.
Do you have a SEVERE allergy to eggs?*

NoYes
Have you ever had Guillian-Barre Syndrome?*

NoYes
Have you ever had a life-threatening reaction to the influenza vaccine?*

NoYes
Should be Empty:

Flu Vaccination Event Registration

Registration Cancellation

Change Appointment

Choose Preferred Date and Time

New patient information

Employment Information

Person Responsible for Bill

Insurance Information

Emergency Contact

Influenza Vaccination Consent