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Schedule Appointment
Flu/COVID vaccines 2024-2025
Online checkin
After Hours Support
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Join Our Clinic
Our Clinic
Why We're Different
How it all Works
Our Team
Style of Care
Testimonials
The Clinic
Clean Air Policy
Advice & Resources
quick triage
COVID-19 info
Medical Advice Library
Links and Resources
Dr. Joel's Blog
Search site
Vaccine Workshop
Contact
Contact Us
Schedule Appointment
Flu/COVID vaccines 2024-2025
Online checkin
After Hours Support
Account Payments
Pay for membership
Join Our Clinic
Flu vaccine scheduling forms
Flu vaccine form - 1 child
Flu vaccine form - 2 children
Flu vaccine form - 3 children
Flu vaccine form - 4 children
Scheduling form for 4 children
For help with any of the items on this form, please view the
FAQs and info section on the main page
.
Parent's contact info
Parent's name
*
First Name
Last Name
Parent's email
*
Phone
*
(###)
###
####
Child 1
Name
*
First Name
Last Name
Child's Age
*
Younger than 12 months
Older than 12 months
Number of doses
*
If your child is less than 9 years old AND hasn't had at least 2 or more doses total in their lifetime, they'll need 2 doses (separated by 4+ weeks). Otherwise, just 1 dose.
1
2
Date(s)
*
If your child needs 2 doses, select two dates, otherwise select just one date.
During a scheduled well check
Flu clinic Friday 11/22/2019 4-7pm
Child 2
Name
*
First Name
Last Name
Child's Age
Younger than 12 months
Older than 12 months
Number of doses
*
If your child is less than 9 years old AND hasn't had at least 2 or more doses total in their lifetime, they'll need 2 doses (separated by 4+ weeks). Otherwise, just 1 dose.
1
2
Date(s)
*
If your child needs 2 doses, select two dates, otherwise select just one date.
During a scheduled well check
Flu clinic Friday 11/22/2019 4-7pm
Child 3
Name
*
First Name
Last Name
Child's Age
*
Younger than 12 months
Older than 12 months
Number of doses
*
If your child is less than 9 years old AND hasn't had at least 2 or more doses total in their lifetime, they'll need 2 doses (separated by 4+ weeks). Otherwise, just 1 dose.
1
2
Date(s)
*
If your child needs 2 doses, select two dates, otherwise select just one date.
During a scheduled well check
Flu clinic Friday 11/22/2019 4-7pm
Child 4
Name
*
First Name
Last Name
Child's Age
*
Younger than 12 months
Older than 12 months
Number of doses
*
If your child is less than 9 years old AND hasn't had at least 2 or more doses total in their lifetime, they'll need 2 doses (separated by 4+ weeks). Otherwise, just 1 dose.
1
2
Date(s)
*
If your child needs 2 doses, select two dates, otherwise select just one date.
During a scheduled well check
Flu clinic Friday 11/22/2019 4-7pm
Comments
Most questions are answered in the FAQ and info section of the main page. If not, please add any comments or special circumstances here. Thanks!
Thank you!
