Flu Clinic on October 22, 2020

Register for the Flu Clinic on October 22, 2020 at the Little Valley American Legion, 5899 NY-353, Little Valley, NY 14755.

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Patient Name

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Do you have health insurance?

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Health Insurance Info

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Health Insurance ID

Group Number

Health Insurance Group Number

Screening Checklist

Screening Checklist for Contraindications to Inactivated Injectable Influenza Vaccination

For patients (both children and adults) to be vaccinated: The following questions will help us determine if there is any reason we should not give you or your child inactivated injectable influenza vaccination today. If you answer "yes" to any question, it does not necessarily mean you (or your child) should not be vaccinated. It just means additional questions must be asked. If a question is not clear, please ask your healthcare provider to explain it.

Is the person to be vaccinated sick today?

Does the person to be vaccinated have an allergy to a component of the vaccine?

Has the person to be vaccinated ever had a serious reaction to influenza vaccine in the past?

Has the person to be vaccinated ever had Guillain-Barre syndrome?

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Flu Clinic on October 22, 2020

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