2025-2026 Flu Vaccine ages 5-64 years

Seasonal Flu Vaccine: Ages 5-64 years
Demographic Information
Age of person to be vaccinated (must be 5 or older on date of appointment)*
Unfortunately, we can only adminster vaccine to children aged 5 and older.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Date of Birth*

MonthDayYear
Date
Gender at Birth*
Race*
Ethnicity*

Consent

You need to read each statement and check the box before you will be allowed to sign the form. If you are completing this form for a minor, you will be asked to physically sign an additional consent form at their vaccine appointment.*

	Check Each Box
I understand the benefits and risks of the Seasonal Influenza Vaccine as described in the Vaccine Information Sheet, a copy of which I was provided with this consent form. I have had a chance to ask questions and they were answered to my satisfaction. I request the vaccine be given to me or the person named above whom I am responsible for. Vaccine information sheets are available below.
I agree to stay in the vaccine administration area until I am dismissed by an immunizer.
I understand that as required by state law, all immunizations will be reported to the Department of Public Health Massachusetts Immunization Information System (MIIS). I understand that I can access the MIIS Fact Sheet, which has been provided to me with this consent form, to get more information on the MIIS and what to do if I object to sharing of my/my child's immunization information.

Seasonal Flu Vaccine Information Sheet (VIS) 01.2025
Consent for Patients Under 17- You will be provided a copy of this form to sign at your child's appointment.
MIIS Fact Sheet
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*

I/my child have insurance. By choosing this option I am authorizing Inman Pharmacy, INC to bill by medical or pharmacy insurance to cover the vaccine and vaccine administration cost. If my insurance does not cover the cost of the vaccine or administration I may be charged. I understand the pharmacy may contact me to obtain additional information if necessary.I/my child do not have insurance. I agree to pay out of pocket for the vaccine(s) and administration costs as applicable.
Please upload a copy of your insurance card. If you have Medicare Part B, please upload that card. If you do not wish to upload a copy of you card, we recommend you call the pharmacy with the information to ensure coverage prior to your appointment.

Cancelof
Signature of Person to Receive Vaccine: I attest that all of the information provided on this form is accurate*

Clear
Date Signed*

MonthDayYear
Date

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:

Seasonal Flu Vaccine: Ages 5-64 years

Demographic Information

Screening Questions

Consent

Schedule Your Appointment