2025-2026 Vaccine Clinic

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Parent Name* This field is required.

First Name

Last Name

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Email* This field is required.

example@example.com

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Phone Number* This field is required.

Please enter a valid phone number.

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Has your insurance changed since your last office visit?* This field is required.

YESNO

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Please upload an image of your new insurance card.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

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How many children will be getting vaccinated during this appointment?* This field is required.

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Would you like an appointment on a weekday (Tu/Wed/Th 8:30am-4:30pm) or Saturday (1pm-4pm)* This field is required.

Weekday

Saturday

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Weekday Appointments* This field is required.

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Saturday Appointments* This field is required.

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Child {childNumber}'s Name* This field is required.

First

Last

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{childName:first}'s Date of Birth* This field is required.

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{childName:first}'s Age* This field is required.

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Will {childName:first} be 6-months of age or older at this appointment?Your child must be at least 6 months to receive their first Flu Shot and Covid-19 vaccine.

Yes

No

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What vaccine(s) is {childName:first} scheduled to receive?* This field is required.

Influenza (2025-2026 season) (Only Flu Vaccine available at this time)

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Which type of Flu Vaccine will be given to {childName:first}?* This field is required.

Flu Shot

FluMist (influenza live, Intranasal)

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For children under 9 years of age, is this a booster dose of the Flu vaccine for the 2025-2026 season?* This field is required.

Yes

No

N/A

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Has {childName:first} ever had Guillain-Barre Syndrome (GBS)?* This field is required.

Yes

No

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Does {childName:first} have a history of asthma or had an episode of wheezing in the last 12 months?* This field is required.

Yes

No

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Did {childName:first} receive Varicella (Chickenpox) or MMR vaccine in the last 4 weeks?* This field is required.

Yes

No

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Has {childName:first} taken Tamiflu or Xofluza in the LAST 48 hours?* This field is required.

Yes

No

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Is {childName:first} allergic to anything including any food, any vaccine, any vaccine component, latex, or polyethylene glycol?* This field is required.

Yes

No

Do Not Know

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Has {childName:first} had an adverse reaction to a vaccine?* This field is required.

Yes

No

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FDA Vaccine Information Statement: Flu shotPlease read the "FDA Vaccine Information Statement" in the PDF viewer on the next page. If you still have questions or concerns after reviewing this material, please contact our office.

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FDA Vaccine Information Statement: FlumistPlease read the "FDA Vaccine Information Statement" in the PDF viewer on the next page. If you still have questions or concerns after reviewing this material, please contact our office.

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Vaccine Consent

I have reviewed the Vaccine Information Statement on the previous page(s).

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Vaccine Consent

I have reviewed the Vaccine Information Statement on the previous page(s).

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Consent break

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Consent Text

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Acknowledgment of Informed Consent* This field is required.By signing below, I, {parentName}, acknowledge that: {consentText} I understand the benefits and risks indicated and ask that the vaccine(s) be given to {childName} for whom I am authorized to make this request. I also understand that I should NOT bring my child to their vaccine appointment if they are sick or in quarantine for Covid-19 exposure.

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apptString

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primaryEntry

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ChildNumber

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NextChildNumber

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apptDateTime

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After pressing Submit below you will be taken to a new form entry for child # {nextChildNumber} of {howManyChildren}