Immunization Clinic Registration Form

Flu Clinic Registration Form
*Complete one Form for Each Person Receiving Services*

On the day of your appointment, we ask that you bring the following items for each person receiving services:
- Identification Card
- Insurance Card

Vaccines

The Flu Clinic has additional vaccinations upon request
Which Flu Clinic are you planning on attending? *
Name of the flu clinic you plan on attending:
Besides the flu shot, are there any other vaccines you’d like today? (Select all that apply)*

COVID VaccineMMR VaccinePneumonia VaccineRSV VaccineShingles VaccineTdap VaccineNone, Flu Vaccine only
Do you give permission for us to check your immunization records in the state registry (imMTrax) to confirm your vaccination history?*

YesNo

Health Insurance Information

Please provide your insurance and policy holder information, if applicable. We ask that you upload the front and back of your insurance card.
Do you have insurance?*

YesNo
Name of Insurance Company *
ID #: *
Group #: *
Name of Policy Holder: *
Birthdate of Policy Holder

MonthDayYear
Date of Birth
Social Security # of Policy Holder *
Relationship to Patient*

SelfSpouseChildOther
Upload the front and back of your insurance card (please still bring copy to the day of appointment).

(acceptable file format: pdf, doc, docx, zip, jpg, jpeg, png, gif)
Cancelof
Date*

MonthDayYear
Signature*

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Flu Clinic Registration Form