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.