Clone of Flu Shot Clinic 2025

Flu Shot Sign-Up Form

Please accurately complete all parts of this form and submit it by clicking "Add me to the list". Flu shots available are for ages 6 months and up, and we do have limited supply of high-dose flu shot for those 65 and older.
We are offering the following flu shot clinics this year:

Bloomfield Farmers Market, Saturdays from 9a-1p:

September 19, 2026

October 10, 2026

October 31, 2026

Lawrenceville Farmers Market, Tuesdays from 3p-7p:

September 22, 2026

October 27, 2026
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
Cell phone number

Area CodePhone Number
Which flu shot clinic do you plan to attend?
Payment information

Insurance carriers will be billed for the flu vaccine. If your insurance does not cover it or you do not have insurance, please note that the cost of the Flulaval vaccine (ages 6 months and up) is $25 and Fluzone High Dose (ages 65+) is $70. Payments can be accepted as cash, credit, or debit.
Accepted Insurances
Do you have insurance?
Insurance carrier
i.e. UPMC, Highmark, etc
Policy number
If you can, please upload a picture of your insurance card

Browse Files

Cancelof
Medicare number, if applicable
Group number
If you are a spouse or dependent of the insured, please write their name
Date of birth of insured

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Are you allergic to eggs?
Have you ever had a severe reaction to the flu vaccine?
Have you had Guillain-Barre Syndrome after a flu shot?
Please click the box below if you will be wanting the high dose flu shot (for those 65 and older)
Should be Empty:

Flu Shot Sign-Up Form

Payment information