Parent/Caregiver Registration form for Flu Vaccine

Parent/Caregiver Registration Form for Flu and / or COVID Vaccine

Please complete 1 form per parent/caregiver
ATTENTION PARENTS:

IF YOU ONLY NEED AN APPOINTMENT FOR YOUR CHILD PLEASE USE THE PATIENT PORTAL. Click the link to go directly to the sign in page.

Westside Pediatrics Patient Portal

THIS FORM IS FOR PARENTS WHO ARE SCHEDULING APPOINTMENTS FOR THEMSELVES AND/OR THE CAREGIVER.
Parent/Caregiver Information*

First & Last NameDate of Birth
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Which vaccine are you scheduling?*

Flu Vaccine (6mo - 64 years old)COVID VaccineFLU & COVID Vaccine
Please tell us the name of your child(ren) including DOB that is in the practice:*
Healthcare Questionnaire
Have you now or ever in the past had any reaction(s) to any vaccines?*

YesNo
WOMEN: are you currently pregnant or is there a possibility of being pregnant?*

YesNo
If you answered yes to either of these questions, please review your answer with your healthcare provider.

Parent/Caregiver Registration Form for Flu and / or COVID Vaccine