The Fremont Vaccine Clinic

Please fill out form below prior to the vaccine clinic on Thursday October 5th 9AM

First name

Last name

Date of Birth

Street Address

City

Region/State/Province

Postal / Zip code

Phone

INSURANCE CARD

Vaccines Needed

Flu (Fluzone HD 65+) (yearly)

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

Pneumonia (1 before 65 yo, then one after turning 65) ***MUST BE BILLED BEFORE CLINIC***

Shingrix (Shingles 2 shots) ***MUST BE BILLED BEFORE CLINIC***

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Vaccine Consent

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