ICHS/Healthpoint Evergreen Flu Clinic
Please fill out this form if you are interested in receiving a no-cost flu shot outside of the Healthpoint Evergreen Campus Health Center on on Tuesday, December 29th.
Phone Number/ Email
Please write the Name and Date of Birth for every person who would like to get a flu shot
Do you have anyone in your group who is....
Additional information may be needed for anyone under these categories
Over 65 years old?
Under 8 years old and have never had the flu vaccine before?
Under 6 months old?
What time are you planning on coming?
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This form was created inside of International Community Health Services.