New york putnam county 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name and date of birth in the designated fields. Ensure that all information is accurate for proper identification.
3. Fill in your address, city, state, and zip code. This information helps in maintaining accurate records.
4. Select your sex by checking either 'Male' or 'Female'.
5. Provide your phone number for any follow-up communication regarding the vaccination.
6. Enter your doctor’s name and address if applicable, along with your Medicare Claim Number if you are using Medicare.
7. Answer the health-related questions regarding fever, previous flu shots, allergies, pregnancy status, and Guillain Barre syndrome by selecting 'Yes' or 'No'.
8. Read the consent statement carefully. If you agree, sign and date at the bottom of the form.
9. Leave the area below for completion by a nurse after vaccination. This includes details about the vaccine administered.

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