Flu Shots

Influenza/Flu Shot Form - Southeast District Health Department

Location/Business

Full Name

First Name *

Middle

Last Name *

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Postal Code *

Date of Birth (mm/dd/yyyy)

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Name of Insurance Provider:

Insurance ID Number:

Primary Policy Holder's Information:

First Name *

Last Name *

Date of Birth:

Address:

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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