2017 Flu Drive Thru Clinic Intake Form - co kittitas wa us-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name in the designated fields: Last, First, and Middle Initial. Ensure accuracy for proper identification.
3. Fill in your mailing address, including City and Zip code. This information is crucial for communication purposes.
4. Indicate your sex by selecting the appropriate checkbox. Provide your home phone number for any follow-up communications.
5. Enter your age and birth date to help assess eligibility for vaccination.
6. If applicable, provide your Medicare number in the specified section.
7. Answer the health questions regarding allergies and previous reactions to vaccines by checking 'YES', 'NO', or 'UNSURE'.
8. Indicate how you heard about the clinic by checking one of the options provided.
9. Review the consent statements carefully, then sign and date at the bottom of the form. If you are a guardian, print your name as well.

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