NEOMED Students/Faculty/Staff Flu Clinics - NEOvations Pharmacy Services (2025-26)

Immunization Administration Record

Influenza (Inactivated) Vaccine
Name*

First NameLast Name
Address*
City*
State*
Zip*
Phone*
Please enter a valid phone number.
Email*
example@example.com
DOB*

MonthDayYear
Date
Gender:*

MaleFemaleWish not to disclose
Weight (if < 66lbs)
Primary Care Provider (PCP)
Which vaccine(s) would you like to receive?*

Influenza (flu)COVID-19 (2025-26 formulation)

NEOMED Flu Clinics

Date	Day	Time	Location
9/15/25	Monday	11:00A - 1:00P	Regula Training
9/18/25	Thursday	12:00P - 3:00P	Regula Training
9/30/25	Tuesday	12:00P - 2:00P	Regula Training
10/3/25	Friday	12:00P - 3:00P	Regula Training
10/22/25	Wednesday	12:00P - 2:00P	Regula Training
10/31/25	Friday	11:00A - 1:00P	Regula Training

All Clinic Dates are Available for ALL Students, Faculty, or Staff.

Flu Shot Clinics will be taking place in the Regula Training Room in the South Corridor (across from the Great Hall).

Select Appropriately with what best describes you:

COMCOPCOGS/MASCODNEOMED EmployeeFamily Member of EmployeeOther
COM

M1M2M3M4
COP

P1P2P3P4
COD

D1D2D3D4
Appointments Open to ALL Groups

(including any family member)
ALL Groups Appointment
ALL Groups Appointment
ALL Groups Appointment
ALL Groups Appointment
ALL Groups Appointment
Employee Name:
Other:

Precautions and Contraindications: Please Check "Yes or No" for each question. *

	Yes	No	Notes
Are you sick today?
Do you have allergies to antibiotics (neomycin, polymyxin-B), eggs, a vaccine component or latex?
Have you ever had a serious reaction after receiving a vaccination?
Have you experienced Guillain-Barre syndrome within 6 weeks of receiving a previous flu vaccines?

All influenza vaccines are administered in accordance to the recommendations made by the Advisory Committee on Immunization Practices (ACIP) and Centers for Disease Control and Prevention (CDC).
Insurance Information NOT required if NEOMED Student only receiving flu vaccine (Required if receiving COVID-19 Vaccine)

(required for ALL others)
Do You Have Medical/Rx Insurance?

YesNo
Cardholder Name:
Cardholder Date of Birth (MM/DD/YYYY)
Relationship (i.e. cardholder, spouse, child)
Medical Insurance Card Image

Cancelof
MEDICAL Insurance Provider Name (eg: Aetna, Cigna, AultCare, etc.)
MEDICAL Insurance ID #
MEDICAL Insurance Group Number
Rx Insurance ID
Rx BIN Number
Rx Group (GRP) Number
Rx PCN Number
If you selected YES, please confirm the statement below:

I agree the insurance information provided is accurate and will be used to bill for the influenza vaccine I receive. It is my responsibility to check with my insurance for network coverage. **Flu vaccine for NEOMED employees under AultCare insurance is covered as a preventative service at no charge.**
Influenza Vaccine Information Statement
COVID-19 Vaccine Information Statement
Joint Notice of Privacy Practices (“Notice”)*

The Joint Notice of Privacy Practices (“Notice”) describes your rights in regard to your protected health information, the possible uses of your protected health information, and how we must protect the confidentiality of your protected health information. By checking here, you are stating you have received a copy of the "Notice" which is provided to you electronically below.
Joint Notice of Privacy Practices ("Notice")
Signature (Patient or Legal Guardian if 7-18 yo)*

Clear
Print Name*
Date*

MonthDayYear
Date
Please preview and print VIS/Privacy Policy PDFs before hitting submit. Thank you!

Flu Shot Clinics will be taking place in the Regula Training Room in the South Corridor (across from the Great Hall).
ALL Groups Appointment
Should be Empty:

Immunization Administration Record

Appointments Open to ALL Groups

Insurance Information NOT required if NEOMED Student only receiving flu vaccine (Required if receiving COVID-19 Vaccine)