Whitesville Meal Site (Firehall) Flu Immunization Appointment 10-13-2026
Thank you for your interest in receiving a Flu Immunization. Please fill out the intake form and schedule a time to receive it below.
Name
*
First Name
Middle Name
Last Name
Birth Date (DOB)
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
DOB
SEX
*
Female
Transgender
Male
Prefer not to answer
Other
Have you received any immunizations under a different last name? If yes, enter name
If Yes, please enter name.
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of responsible person (if not self):
First Name
Last Name
Responsible person (Relationship to person receiving immunization)
Mother, Father, Grandparent, Etc.
Please check all that apply:
*
Has Medicaid/Medicaid Managed Care
Not Insured/No Insurance
American Indian/Alaska Native
Underinsured
Child Health Plus B
Insurance covers immunizations
Name of Insurance
Please name your insurance provider.
Medical Information about the person to receive vaccine:
Please answer each question by checking the appropriate answer (Yes, No, Don't Know)
Does the person being immunized have allergies to medications, latex, food, or any vaccine?
*
Yes
No
Don't Know
Has the person being immunized had a serious reaction to a vaccine in the past?
*
Yes
No
Don't Know
Has the person being immunized had a seizure, a brain problem, or Guillain-Barre Syndrome?
*
Yes
No
Don't Know
Does the person being immunized have cancer, leukemia, AIDS, or any other immune system problem?
*
Yes
No
Don't Know
Has the person being immunized taken cortisone, prednisone, other steroids, or anticancer drugs or had x-ray treatments in the past 3 months?
*
Yes
No
Don't Know
Does the person being immunized currently smoke, use any type of nicotine delivery system, or vape?
*
Yes
No
Don't Know
Does anyone residing within the home of the person being immunized currently smoke, use any type of nicotine delivery system, or vape
*
Yes
No
Don't Know
Please read:
I have read all the vaccine information sheets (linked above) I/my child is eligible for, as well as the Patient Bill of Rights and understand the benefits and risks of receiving the vaccines/screening. I have had an opportunity to ask questions which have been answered to my satisfaction. I authorize Allegany County Department of Health to administer the vaccine(s) provided today to my child/me, declining those not provided, and I give permission for the release of this information to New York State Immunization Information System (NYSIIS), our respective physicians, and upon request to schools or community agencies, for the purpose of providing proof of immunization status. This authorization will expire upon declination of NYSIIS consent. I understand my insurance will be billed but I am responsible for payment if insurance doesn't cover the vaccination. I am responsible for any co-pays and/or deductibles. If I am over 19 years of age I voluntarily give consent for my immunization and identifying information to be released to NYSIIS.
Patient/Parent Signature:
*
Date of signature
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Email - Please enter your email address if you would like an appointment reminder.
example@example.com
Flu Immunization Appointment
*
Please verify that you are human
*
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Should be Empty: