• 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*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Screening Questions

  • Are you/your child feeling sick today?*
  • Are you pregnant?*
  • 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?*
  • 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

  • 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.*
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  • Seasonal Flu Vaccine Information Sheet (VIS) 01.2025
  • 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*
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  • Date Signed*
     - -
    2 digit month, 2 digit day, 4 digit year

  • 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: