Fordland Housing Vaccine Clinic

Please fill out form below prior to the vaccine clinic on Wednesday October 4th 1-2 PM

First name

Last name

Date of Birth

Street Address

City

Region/State/Province

Postal / Zip code

Phone

INSURANCE CARD

Vaccines Needed

Flu (Fluxone HD 65+) (yearly)

Covid-19 Booster 2023 Formulation (Moderna) ***PENDING AVAILABILITY***

Prevnar 20 Pneumonia Vaccine (At least 1 year after other Pneumonia Vaccine) ***MUST BE BILLED PRIOR TO CLINIC***

Shingrix (Shingles 2 shots) ***MUST BE BILLED PRIOR TO CLINIC***

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VAccine consent

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