Welcome! Please complete the survey form to register for the Drive-thru Flu Clinic.

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* 1. Patient First Name

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* 2. Patient Last Name

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* 3. Patient Middle Initial

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* 4. Patient Date of Birth

Date / Time

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* 5. Is the Patient (Please Check)

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* 6. Phone Number

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* 7. Gender (Check One)

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* 8. Tobacco Use

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* 9. Ethnicity

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* 10. Race

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* 11. Parent or Legal Guardian's Name

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* 12. Home Address - (Mailing Address- No P.O. Boxes)

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* 13. City

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* 14. State

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* 15. Zip Code

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* 16. (Required to Answer if patient is under 18 years of age) - Your Relation to the Patient, if not Parent or Legal Guardian

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* 17. (Required to Answer if patient is under 18 years of age) - Your Name if Not Parent or Legal Guardian

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* 18. Source of Payment

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* 19. Does the Patient have private insurance, Medicaid, or Medicare?

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* 20. Does the Patient's insurance cover the immunizations requested today? 

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* 21. Patient's Primary Insurance Coverage (Please Check ALL that Apply) -*We cannot accept Anthem or Tricare Insurance

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* 22. Insurance ID/ Member #

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* 23. Does the patient have a secondary insurance?

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* 24. How did you hear about the Drive Thru Flu Clinic?

0 of 24 answered
 

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