Billing information

First Name:         *

 Last Name:         *

Mailing Address:

City:          State:              Zip:   

E-Mail Address: * Email will only be used for immunization information. No Solicitations.

Phone Number:  * (Please, no spaces, dashes, etc.)  

 ID #: * (See example cards above:)

Please fill out the information below for the Employee and Family Members requesting immunizations.

*You may click on the name of any immunization for vaccine information. You may select more than one.

*Pressing enter at any time will submit your request and you will need to start over if request is incomplete.

Employee  Immunization Requests:

First Name: Last Name:  

Date of Birth:   

       Flu: Should be given to everyone  annually in fall to prevent influenza - AGES 4 & UP ONLY - Younger children must see  their pediatrician.

       Pneumonia: For older adults or people with decreased resistance to infection.

       Tetanus/Diphtheria/Pertussis-Adacel : For 11-18yr olds, and 19-64 one time for the next dose.

       Hepatitis A: 2 shot series 6 months apart, disease transmitted via food or human waste.

       Hepatitis B:  3 shot series, 2nd booster in 30 days, 3rd booster after 6 months, disease usually  transmitted via blood or body fluid contact.

       HPV-Gardasil: For females 9-26, prevents some cervical cancers caused by Human Papillomavirus, in a 3 shot series. Initial dose, 2nd booster in 60 days, 3rd booster in 6 months.

       Meningococcal: Recommended for all children ages 11-18 and is required for most students entering college.

(Click here to submit request or continue entering family member request below)

 Family Member Immunization Requests:    

First Name: Last Name:  

Date of Birth:

       Flu

       Pneumonia   

       Tetanus/Diphtheria/Pertussis-Adacel 

       Hepatitis A

       Hepatitis B 

       HPV-Gardasil                       

       Meningococcal

(Click here to submit request or continue entering family member request below)

 Family Member Immunization Requests:    

First Name: Last Name:  

Date of Birth:   

       Flu

       Pneumonia  

       Tetanus/Diphtheria/Pertussis-Adacel 

       Hepatitis A  

       Hepatitis B 

       HPV-Gardasil                       

       Meningococcal

(Click here to submit request or continue entering family member request below)

Family Member Immunization Requests:  

First Name: Last Name:  

Date of Birth:  

       Flu 

       Pneumonia

       Tetanus/Diphtheria/Pertussis-Adacel 

       Hepatitis A

       Hepatitis B

       HPV-Gardasil                         

       Meningococcal

(Click here to submit request.)

  ( To request additional immunizations for more family members you will have to fill out another complete form )

Questions or comments:

(Click here to submit request.)