Flu Vaccination Registration Form (2025) South DeKalb 1003

DRIVE THRU FOR A FLU-FREE SEASON

(For internal use only – Confidential Health Information)
Event: Community Flu Drive
Date: Friday, October 3, 2025
Time: 9 a.m. - 1 p.m.
Location: South DeKalb Senior Center, 1931 Candler Rd., Decatur, GA 30032
Notice of Privacy Practices: Your information will be used to provide your flu vaccination, bill insurance (if applicable), and maintain immunization records as required by law. Your information will be kept confidential according to HIPAA regulations.
Patient Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medical Information
Allergies (list all medication/food/latex allergies):
Insurance Information

If you have insurance, please enter the information below
Insurance Carrier
Member ID / Policy #:
Should be Empty:

DRIVE THRU FOR A FLU-FREE SEASON