PLEASE READ BELOW: 

• PRINT & FILL OUT THIS FORM HERE 

• SIGN UP BELOW - ENTER NAMES AND AGES IN THE NOTES SECTION

• BRING YOUR INSURANCE CARD & A PAPER COPY OF YOUR INSURANCE CARD - ALL INSURANCES ACCEPTED
• NO COPAY
• FOR 65 AND OLDER, HIGH DOSE FLU SHOT IS AVAILABLE
• CHILDREN CAN RECEIVE FLU SHOT IF THEY CAN REMAIN SEATED
• Insurance will be billed; no copays.  
• Uninsured will receive a discount.