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Flu Insurance Information Form

  1. 2020 Flu Clinic
    Please fill in the information below for every vaccine recipient. Vaccine is for people 5 years old and up.
  2. Information about the person to receive the vaccine
  3. Must be 5 years of age or older
  4. Format of (xxx)yyy-zzzz
  5. Insurance Information
  6. If person getting vaccinated is not the insurance subscriber/policy holder, please complete the following:
  7. Format of (xxx)yyy-zzzz
  8. Leave This Blank: