Prior to booking your Flu Shot appointment, please complete the form below: Name * First Name Last Name Date of Birth * Gender * Male Female Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Any Allergies? * Any Allergies to Eggs? * Any History of Guillan Barre Syndrome * Any Previous Reaction to the Flu Shot * If the answer to this question is yes, please specify what the reaction was and if you received the flu shot again since your reaction During the past 3 days have you experienced any fever, chills, or aches * Are you on any Immunomodulators or take other Medications that would affect your Immunity * Insurance carrier example: fidelis or oxford * Insurance ID # * Upload the Front & Back of Your Insurance Card Here * FileField; MaxSize=5000KB; Multiple; addText=Upload_Your_Files By checking the box below I consent to the office of Adina Erez the right to release my medical records and test results to an insurance company or third party payer and their agents for the purpose of determining eligibility, benefits and obtaining payments for the services provided for me by this office. In addition, I understand that I am responsible for and will pay the remaining balance not covered by insurance companies, governmental agencies, or third party payers. Lastly, I acknowledge that all bills will be mailed to me by "Community Urgent Care." * I consent and agree I consent and agree Thank you!
