IIT: Register for your flu shot!
Clinic Location
First Name
Last Name

Date of Birth

 
 

Email

Confirm Email

Mobile Phone Number

Gender

You will receive those immunizations as medically indicated by your health consultant staff. Vaccine Information Statements are available online here.

Please bring a driver's license or form of identification with you to the event and dress appropriately to receive an injection in the upper arm. You must complete the insurance information in this link accurately. Walk-ins are welcome and will be accommodated after those who registered online have been serviced.
Services I'd like to receive
Medical History Questions
Yes No Is this your first flu vaccination?
Yes No Have you ever had an anaphylactic reaction, such as hives, wheezing, difficulty breathing or circulatory collapse related to latex?
Yes No Have you ever had an anaphylactic reaction, such as hives, wheezing, difficulty breathing or circulatory collapse related to chicken eggs, egg products, neomycin, gelatin or yeast?
Yes No Have you ever had an anaphylactic reaction, such as hives, wheezing, difficulty breathing or circulatory collapse related to thimerosal, which is found as a preservative in contact lens solution and some vaccines?
Yes No Do you have any history of Guillain-Barre Syndrome or paralysis?
Yes No Are you pregnant or breast feeding?

Insurance Billing Information

Provider Name
Member ID
Group ID
Insured through Self Spouse / Domestic Partner Parent Other
 



Need help? Contact us at vrill@iit.edu


Passport Health is committed to keeping your personal data safe and we endeavor to take every reasonable precaution to ensure security. Passport Health complies with health care data reporting requirements of State and Federal authorities, as well as subpoenas, and may use or disclose data as required or requested for billing and payment purposes. Outside of this, access to your personal information is restricted to employees at Passport Health for internal purposes only and is never sold.