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2. 2020 Flu Clinic
   Please fill in the information below for every vaccine recipient. Vaccine is for people 5 years old and up.
6. Information about the person to receive the vaccine
8. Last Name*
9. First Name*
10. Middle Initial
12. Date of Birth*
    Date of Birth
13. Age in Years*
    Must be 5 years of age or older
14. Sex*
    -- Select One --MaleFemale
16. Street Address*
18. City*
19. State*
20. Zip Code*
22. Phone number*
    Format of (xxx)yyy-zzzz
26. Insurance Information
28. Name of Insurance Company*
29. Member ID number*
30. Group ID number
32. Medicare Number
33. Is Medicare Primary
    -- Select One --YesNo
34. Is Subscriber Retired
    -- Select One --YesNo
38. If person getting vaccinated is not the insurance subscriber/policy holder, please complete the following:
40. Are you the insurance policy holder
    -- Select One --YesNo
42. Subscriber's Last Name
43. Subscriber's First Name
44. Subs Middle Initial
46. Subscriber's Date of Birth
    Subscriber's Date of Birth
47. Subscriber's Sex
    -- Select One --MaleFemale
49. Subscriber's Street Address (if different from above)
51. Subscriber's City
52. Subscriber's State
53. Subscriber's Zip Code
55. Subscriber's Phone number
    Format of (xxx)yyy-zzzz
56. Relationship to Subscriber
    -- Select One --SpouseChildOther
Leave This Blank:


60. Submit

* indicates a required field