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IF YOU ARE UNABLE to come to Polk County Health Department to receive a flu vaccination due to a medical reason, we may be able to send someone to your home to provide the vaccination.

NOTE: Completing this form DOES NOT guarantee that someone will come to your home to give you a flu vaccination.

Please enter your information carefully. If you make mistakes, we may not be able to contact you. We will try to contact you within three days, using the phone numbers you give us.

CONFIDENTIALITY: we are collecting this information only so we can contact you about your request. Your information will not be shared with anyone else.

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* 1. What are the medical reasons for needing a home visit for a flu vaccination (check ALL that apply):

Immune-compromised because of cancer treatment, HIV or organ transplant

Home-bound, or has received bed-rest orders from a doctor

Do not have home health care

Problems walking or does not have any transportation

Other medical circumstances (please specify)

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* 1. What are the medical reasons for needing a home visit for a flu vaccination (check ALL that apply):

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* 2. Please enter the first name of the person who needs assistance

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* 3. Please list the phone number where you can be reached between 8 am and 7 pm, in this format: 111-123-4567

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* 4. Please list a second phone number we can use to contact you, in this format: 111-123-4567.