Flu Clinic Registration - September 30, 2020
IMPORTANT INSTRUCTIONS FOR DRIVE-THRU FLU CLINIC, PLEASE READ: Please complete the screening tool below to pre-register for the flu shot at our drive-thru clinic at the Chatham Fairgrounds on September 30, 2020 from 9:00 a.m. to 11:00 a.m. Please provide a telephone number where you can be reached so that we may contact you for further information if needed. If you have an e-mail address, we will e-mail you your confirmation of pre-registration. If you believe you have successfully registered but have not received an email confirmation within 5 business days, please contact the Health Department by phone or by email to ccdoh@columbiacountyny.com.

If you are sick with any symptoms associated with flu or COVID-19 illness (fever, shortness of breath or difficulty breathing, sore throat, chills, new loss of taste of smell, or extreme headache) please DO NOT come to the drive-thru clinic; please call your primary care doctor or call our office at 518-828-3358 for further guidance.

Pre-registration is required to receive your flu shot on this date. If you do not register ahead of time, you can not be vaccinated at this flu clinic. If you are registering for someone else (e.g. spouse or child), a separate registration form must be completed for each individual. Photo ID is required for each person vaccinated.

If you do not have email but would like to register, please call the Health Department at (518) 828-3358.
Email address *
First Name *
Last Name *
Date of Birth (Ex. 01/07/2019) *
Gender *
Telephone Number (with area code) *
Mailing Address Street *
City/Town *
State *
Zip Code *
Name of Primary Care Physician or Medical Practice *
Have you ever received a flu shot? *
Have you ever had a severe reaction to a flu shot? (If yes, we CANNOT allow you to come to our drive-thru clinic. Please contact your doctor for further guidance). *
Do you have any allergies? *
If you have allergies, please check all that apply:
If you checked "other" above, please list your allergies below:
Are you currently pregnant or breastfeeding? *
Do you have health insurance? *
Primary Insurance (select N/A if not insured or your insurer is not listed below). *
Policy Number *
Secondary Insurance
Policy Number
If you are over the age of 19, the Health Department is required to have permission to enter your immunization into the NYS Immunization Database (NYSIIS). Entering your information will allow yourself and your physician to have access to this record. Please indicate below whether or not you consent.
Clear selection
You must check the box below to provide voluntary consent to receive the influenza vaccination from the Columbia County Department of Health. By checking this box, you are also agreeing to allow CCDOH to bill your insurance, and acknowledging that you will receive a copy of the Patient of Bill of Rights, Notice of Privacy, and the Vaccine Information Statement on the date of administration of the vaccine. *
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