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

Date of Birth

 
 

Email

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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 dress appropriately to receive an injection in the upper arm. If you have BCBS IL PPO/HSA insurance, you must complete the insurance information in this link accurately. Please note that individuals will be responsible for payment of denied claims (which can't be predicted at the time of service) or for non-contracted insurance plans accepted in error. Walk-ins are welcome.
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 Child Other
 



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Passport Health is committed to keeping your personal data safe and we take every reasonable precaution to ensure security. Access to your personal information is restricted to employees at Passport Health. Your personal data is used for internal purposes only and is never sold or shared with anyone outside of Passport Health.