If you do not have insurance, we can still provide you a flu shot at no cost
Clinic Location
First Name
Middle Name
Last Name
Date of Birth
 
 
Parental/Guardian Consent
Please type your full name to electronically affirm consent as registrants parent/legal guardian. Signature
Email
Confirm Email
Insurance Billing Information
Insurance Provider
 
Services I'd like to receive
You will receive those immunizations as medically indicated by your health consultant staff. Vaccine Information Statements are available online here.
Medical History Questions
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? Yes No



Need help? Contact us at accounts@passporthealthusa.com


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.