Flu Shots

Influenza/Flu Shot Form - Southeast District Health Department

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Location/Business

Full Name

First Name *

Middle

Last Name *

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Mailing Address

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City *

State/Province *

Postal Code *

Date of Birth (mm/dd/yyyy)

Sex

Male
Female

Race (Select One)

Ethnicity (Select One)

Name of Insurance Provider:

Insurance ID Number:

Primary Policy Holder's Information:

First Name *

Last Name *

Date of Birth:

Address:

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Primary Policy Holder's Phone Number:

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Relationship to person receiving the vaccine:

Do you have allergies to eggs or any component of the vaccine?

Have you had a serious reaction to a vaccine in the past?

Should you develop symptoms of flu/COVID-19 before the flu shot clinic, please DO NOT come for your flu shot (i.e. cough, fever, headaches, shortness of breath, sore throat, chills, loss of taste or smell, diarrhea, nausea, vomiting, muscle aches).

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Flu Shots

Influenza/Flu Shot Form - Southeast District Health Department

Nebraska City Office

Auburn Office

Tecumseh Office

Nebraska City Office

Auburn Office

Tecumseh Office