Scheduling form for 1 child

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 address

Parent's phone

(###)

###

####

Child

Name

First Name

Last Name

Child's Age

Number of doses to schedule

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.

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!