Primrose Flu Clinic Sign Up

Enter all requested information, then you will be redirected to the scheduling site where you can pick your time slot

Name of person being vaccinated

First Name

Last Name

Date of birth of person being vaccinated

YYYY

Name of second person being vaccinated

First Name

Last Name

Date of birth of second person

YYYY

Name of third person being vaccinated

First Name

Last Name

Date of birth of third person

YYYY

Name of fourth person being vaccinated

First Name

Last Name

Date of birth of fourth person

YYYY

Email address of primary contact person

Phone number of primary contact person

(###)

###

####

Insurance Company Name

Type "self pay" if you will not be using insurance

Insurance Group ID

Insurance Member ID

Primary Insured's Name and DOB