NEOMED Students/Faculty/Staff Flu Clinics - NEOvations Pharmacy Services (2026-27)

Immunization Administration Record

Influenza (Inactivated) & COVID-19 Vaccine
Name

First NameLast Name
Address
City
State
Zip
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
DOB

MonthDayYear
Date
Gender:
Weight (if < 66lbs)
Primary Care Provider (PCP)
Which vaccine(s) would you like to receive?

NEOMED Flu Clinics

Date	Day	Time	Location
9/21/26	Monday	11:00A - 2:00P	AC-106 Training Room
10/2/26	Friday	12:30P - 3:00P	AC-106 Training Room
10/16/26	Friday	12:30P - 3:00P	AC-106 Training Room
10/21/26	Wednesday	11:00A - 2:00P	AC-106 Training Room
10/22/26	Thursday	11:00A - 2:00P	AC-106 Training Room

All Clinic Dates are Available for ALL Students, Faculty, and Staff.

Flu Shot Clinics will be taking place in the AC-106 Training Room (formerly known as Regula Training Room) in the South Corridor (across from the Great Hall).

Select Appropriately with what best describes you:
COM
COP
COD
Appointments Open to ALL Groups

(Please select only one appointment per individual)
ALL Groups Appointment
ALL Groups Appointment
ALL Groups Appointment
ALL Groups Appointment
ALL Groups Appointment
Employee Name:
Other:

Precautions and Contraindications: Please Check "Yes or No" for each question.

Rows	Yes	No	Notes
Are you sick today?
Do you have allergies to antibiotics (neomycin, polymyxin-B), eggs, a vaccine component or latex?
Have you ever had a serious reaction after receiving a vaccination?
Have you experienced Guillain-Barre syndrome within 6 weeks of receiving a previous flu vaccines?

All influenza vaccines are administered in accordance to the recommendations made by regulatory organizations including ACIP, AAP, ACOG, AAFP, IDSA and Centers for Disease Control and Prevention (CDC).
Insurance Information REQUIRED for everyone accept for NEOMED Students only receiving flu vaccine.
Do You Have Medical/Rx Insurance?
Cardholder Name:
Cardholder Date of Birth (MM/DD/YYYY)
Relationship (i.e. cardholder, spouse, child)
Medical Insurance Card Image

Cancelof
MEDICAL Insurance Provider Name (eg: Medical Mutual, Aetna, Cigna, etc.)
MEDICAL Insurance ID #
MEDICAL Insurance Group Number
Rx Insurance ID
Rx BIN Number
Rx Group (GRP) Number
Rx PCN Number
If you selected YES, please confirm the statement below:
Influenza Vaccine Information Statement
COVID-19 Vaccine Information Statement
General Consent
General Consent
Signature (Patient or Legal Guardian if 5-18 yo)
Print Name
Date

MonthDayYear
Date
Please preview and print VIS/General Consent PDFs before hitting submit. Thank you!

Flu Shot Clinics will be taking place in the AC 106 Training Room (formerly Regula Training Room) in the South Corridor (across from the Great Hall).
Should be Empty:

Immunization Administration Record

Appointments Open to ALL Groups

Insurance Information REQUIRED for everyone accept for NEOMED Students only receiving flu vaccine.