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State of Vermont Flu Clinic Registration

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Clinic Location
First Name
Last Name
Date of Birth
Address
City
State
Zip
Employee ID
Email for Registration Confirmation
Confirm Email for Registration Confirmation
Phone Number
Gender
 
You will receive those immunizations as medically indicated by your health consultant staff. Vaccine Information Statements are available online at http://www.cdc.gov/vaccines/hcp/vis/current-vis.html.

WE WILL BE USING AN E-CONSENT SYSTEM FOR REGISTRATION SO THERE IS NO NEED TO PRINT YOUR CONSENT FORM!


There is no out of pocket cost for this vaccination. Your answers to the medical history questions below will be reviewed for accuracy at time of service.



Your Medicare number is required for billing purposes. Please note that a confirmation email will be sent to the email address provided. Your Medicare ID will be partially redacted in that email.


For clinic dates, directions and FAQ, please click here.



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Medical History Questions
Is this your first flu vaccination?
Have you ever had an anaphylactic reaction, such as hives, wheezing, difficulty breathing or circulatory collapse related to latex?
Have you ever had an anaphylactic reaction, such as hives, wheezing, difficulty breathing or circulatory collapse related to chicken eggs, egg products, neomycin, gelatin or yeast?
Have you ever had an anaphylactic reaction, such as hives, wheezing, difficulty breathing or circulatory collapse related to thimerosal, which is found as a preservative in contact lens solution and some vaccines?
Do you have any history of Guillain-Barre Syndrome or paralysis?
Have you received a pneumonia vaccination in the last 5 years?
Are you pregnant or breast feeding?
 
Insurance Billing Information
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Need help? Contact us at accounts@passporthealthusa.com.