Dallas Baptist Church's Drive-Thru Flu Shot Clinic
Registration for flu shot clinic on October 6, 2020 - 9-11 A.M.
Location (402 W. Trade St., Dallas, 28034): Breezeway between the education building and activity building off Maple Street.
You will need to sign a consent form the day of the clinic, and please bring your insurance card to the clinic.
Your information will be shared with CVS of Dallas, NC; your information will be otherwise be kept confidential.
Preferred Time *
Name (First & Last) *
Date of Birth *
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Phone Number *
Address (Street/P.O. Box, City, State, Zip Code) *
Primary Care Provider Name
Primary Care Provider Phone Number
Primary Care Provider Address (Street/P.O. Box, city, state, zip code)
Primary Care Provider Fax Number
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