PH
Public Health
Online Vaccination Screening Forms
The following forms are provided for individuals to complete online. If you complete the form online, please print and sign the form and bring it to the flu clinic with you. Persons with completed online forms will be able to go directly to registration without stopping for screening. It is also recommended that you read the Vaccine Information Sheet prior to attending the clinic.
Intranasal Seasonal Flu Vaccine (FluMist) – This form should be used for persons 2-49 years of age who are healthy (no long-term health problems).
- Screening Questionnaire for Intranasal Influenza Vaccination
- Live, Intranasal Influenza Vaccine Information Sheet
Injectable Seasonal Flu Vaccine – This form should be used for persons 6 months and older and for pregnant women.
- Screening Questionnaire for Injectable Influenza Vaccination
- Inactivated (Injectable) Influenza Vaccine Information Sheet
Public Health will be offering other immunizations at the Flu Clinics. The Screening Questionnaire for Adult Immunization should be completed to receive these other immunizations. Only one Adult Immunization Form is required to receive these additional immunizations. If you complete the form online, please print and sign the form and bring it to the flu clinic with you. Persons with completed online forms will be able to go directly to registration without stopping for screening. It is also recommended that you read the Vaccine Information Sheet prior to attending the clinic.
Tdap (Tetnus, diptheria, pertussis) – Target population is persons having close contact with children under 1 year of age.
Pneumococcal (Pneumonia) – This is for persons 65 years and older who have not received a pneumonia vaccination or who received a vaccination prior to age 65 and it has been at least 5 years since the vaccination. Some other people may receive the vaccine if they have a chronic condition listed in the Vaccine Information Sheet.
