HFC Flu Shot Registration

HFC Flu Shot Registration

Please fill out the form below to register. If you choose private pay, please be prepared to pay on the day of your visit. Our Registration Staff will call you prior to the event to confirm details. Please call the office at 402-463-2929 with questions.
Name

First NameLast Name
Date of Birth

DayMonthYear
Gender
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
How will you be paying for your flu shot?

Private payBill my insurance
Which shot would you like?

$35 regular shot$65 high-dose shot
If paying via insurance, please list your insurance company and group number:
October 11, 2025
Should be Empty: