Scheduling form for 3 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 *
Parent's name
Phone *
Phone
Child 1
Name *
Name
Note: the nasal (Flumist) will not be offered this year due to recent data finding the current version far less effective than the good old fashioned shot. We hope in future years they may find a way to improve this, but until then we will only be recommending the shot.
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.
Child 2
Name *
Name
Note: the nasal (Flumist) will not be offered this year due to recent data finding the current version far less effective than the good old fashioned shot. We hope in future years they may find a way to improve this, but until then we will only be recommending the shot.
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.
Child 3
Name *
Name
Note: the nasal (Flumist) will not be offered this year due to recent data finding the current version far less effective than the good old fashioned shot. We hope in future years they may find a way to improve this, but until then we will only be recommending the shot.
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.
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!