Influenza Vaccine Screening Questions

*Must be 13 years or older.
*Masks: Everyone in the car is required to wear a mask.
*Seating: The patients receiving the vaccine must be seated next to an accessible door. We will not be entering the vehicle to give vaccinations. (Limit - 4 patients per carload)
*Stay Home If Sick: If you or the patient has symptoms like fever, cough, congestion, loss of smell, etc. cancel your appointment through your patient portal or by calling the call center at (914) 909 6754.
*High Dose of the Influenza Vaccine will not be offered.
*After completing the form, a Patient Service Representative will contact you to set up an appointment.

Notice:
We are currently only offering the Influenza vaccine to anyone over 13 years of age at our drive through facility only. Please contact your primary care physician at this time. If you do not have a primary care physician, please contact our Internal Medicine department at 914-594-2400 for an in person visit. 






Notice:
Due to selecting YES to any of the questions #2-#7, you have not met the WMC Criteria for obtaining the influenza vaccine at our drive through facility. Please contact your Primary Care Physician at this time. If you do not have a primary care physician, please contact our Internal Medicine department at 914-594-2400 for an in person visit. 
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PATIENT DEMOGRAPHICS


INSURANCE INFORMATION


 (Ex: United Healthcare, Aetna, BlueCross Blue Shield etc.) 




Consent
I have read the document in the link below and consent to the vaccine.
https://www.cdc.gov/vaccines/hcp/vis/vis-statements/flu.pdf