• Seasonal Flu Vaccine: Ages 5-64 years

  • Demographic Information

  • Unfortunately, we can only adminster vaccine to children aged 5 and older.

  • Format: (000) 000-0000.
  • Date of Birth*
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  • Screening Questions

  • Are you/your child feeling sick today?*
  • Do you/your child have allergies to any medications, food, a vaccine component, or latex?*
  • Have you/your child had a serious reaction after receiving a vaccine?*
  • Do you/your child have any long-term health problems with the heart, lungs, kidneys*
  • Do you/your child have any of the following medical conditions: diabetes, asthma, a blood disorder, a cochlear implant, a spinal fluid leak, or no spleen?*
  • Do you /your child have cancer, leukemia, HIV/AIDS, or any other immune system problems?*
  • Do you/your child have a parent or sibling with an immune system problem?*
  • In the past six months, have you/your child taken medications that affect your immune system, such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn's disease, or psoriasis; or have you/your child had radiation treatments?*
  • Have you/your child had a seizure or a brain or other nervous system problem?*
  • Have you/your child ever been diagnosed with a heart condition (myocarditis or pericarditis" or have you/your child had Multisystem Inflammatory Syndrome (MIS-A or MIS-C) after an infection with the virus that causes COVID-19?*
  • In the past year, have you/your child received immune (gamma) globulin, blood/blood products, or an antiviral drug?*
  • Are you pregnant?*
  • Have you/your child received any vaccinations in the past 4 weeks?*
  • Have you/your child ever felt dizzy or faint before, during, or after a shot?*
  • Are you/is your child nervous about getting a shot today?*

  • Consent

  • Rows
  • Seasonal influenza is commercially available. If you do not have insurance, you may be eligible for free vaccine through a Department of Public Health Clinic. Please choose only one option below*
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  • Date Signed*
     - -

  • Schedule Your Appointment

  • We are located at 1414 Cambridge Street (Inman Square) Cambridge, MA 02139. When you arrive for you appointment, please check in at the register. Once you are checked in you will be directed to the immunization area. We will need access to your the deltoid region of your shoulder. Please plan your dress accordingly. If you have any questions, or would like to cancel/change your appointment please call the pharmacy at (617) 876-4868

  • Appointment*
  • Should be Empty: