Clone of FLU Clinic for Racine Dominicans

FLU Shot Enrollment

The following information you provide is required to bill to your medical insurance. This form is secure and HIPAA compliant.
If you have any questions or need assistance, please call 262.632.0520.
Section I. Personal Information
Patient's Full Name:

First NameMlLast Name
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Age:
Address:

Street Address Line 2
Gender:
Cell Phone Number:
Race:
Ethnicity
Email:
This information is required to confirm your appointment upon submission.
Primary Care Doctor:
Social Security #
May be needed to assist in locating insurance coverage
Section II. Questionnaire for Immunization

Please select the correct option below:

Rows	Yes	No	Don't know or N/A
Questionnaire for Immunization: 1. Are you feeling sick today?
2. Do you have any allergies to any component(s) of the vaccine?
3. Have you ever had a serious reaction to the influenza vaccine in the past?
4. Have you every had Guillain-Barre Syndrome?

Please specify the allergy from Q2:
Section III. Signature
I have received a copy of the notice of Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.
Signature of Acknowledgment of Notice of Privacy Practices:
Section IV. Insurance
Do You Have Insurance?
If you have medical insurance, please take a photo of the front and back of your insurance card, and use the following link to upload the photos. If you are unable to upload the photos, please complete the information in the following section.

Browse Files

Cancelof
Commercial Insurance

If you are unable to upload photos of your insurance card, please complete the following section.
RX Bin Number:
RX Bin
RX PCN Number :
RX PCN
RX Group Number :
RX Group
ID Number :
IN Number
Medicare Part B Insurance (Red, White, & Blue Card)

If you have Medicare Part B Insurance, please provide your ID#
Medicare Part B ID#:
ID #
By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.
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