2022 PHC FLU CLINICS - SEPT. 24 & OCT. 1

1
Dear PHC Families,

We are passionate about keeping your children protected from influenza and we believe the drive-thru/curbside model is the safest and most effective way to vaccinate our established patients this year.

Therefore, we are excited to announce that we still have availability for our drive-up flu clinic on Oct. 1, 2022

Please keep in mind that WEATHER MAY IMPACT THESE CLINIC DATES AND WE WILL NOTIFY YOU IF THERE ARE ANY CHANGES.

To keep things running smoothly and efficiently, we need your help and cooperation.

Please read each section carefully AND fill out all required fields.

Please watch the short video below in its entirety to prepare for your visit.

THE FORMS BELOW MUST BE COMPLETED, PRINTED, AND BROUGHT WITH YOU ON THE DAY OF THE CLINIC.

Please ensure that our office has your insurance information on file as we are unable to take your cards on the day of the clinic.

Please complete your appointment scheduling at the end of this form.

Please schedule a separate appointment for each child. If you are having difficulty, please contact our office at (586) 254-7593 to schedule instead.***

Thank you for your cooperation!
2
PEDIATRIC HEALTHCARE FLU CLINIC VIDEO:Please watch the entire video so that you will be prepared for your curbside vaccination.
3
THINGS TO REMEMBER

WE DO NOT CARRY MEDICAID VACCINES AT OUR OFFICE.

You MUST complete your appointment scheduling at the end of this form.

You must print out and bring the completed Flu Shot Form for each child to the clinic. Please complete the top portion. The parent signature will be done at the clinic.

If you are unable to print the forms at home, please call or text our office for assistance BEFORE THE DATE OF THE CLINIC. Please note that a copy of the forms will also be emailed to you along with your appointment confirmation.

IF ANYONE IN THE HOME IS EXPERIENCING SYMPTOMS OF ILLNESS OR FEVER OR IF FORMS ARE NOT COMPLETED, YOUR APPOINTMENT WILL NEED TO BE RESCHEDULED. PLEASE CALL US AT (586) 254-7593 FOR MORE DETAILS.

IF YOU HAVE HAD A REACTION TO A PAST FLU VACCINE, PLEASE CONTACT THE OFFICE TO DISCUSS WITH YOUR PROVIDER.

The clinics are for FLU SHOTS only. No nasal spray will be given at clinics.

All parents & children participating in the Flu Clinic MUST be wearing a mask.

On the day of the clinic, please seat your child in the car so they are accessible from outside the vehicle. Your child may remain in their car seat. Please dress appropriately to allow access to your child's arm (patients age 4 and older) or leg (patients age under 4).

NO RESTROOMS ARE AVAILABLE.
4
NAME OF PARENT/LEGAL GUARDIAN COMPLETING THIS FORM:* This field is required.
First Name
Last Name
5
PLEASE PROVIDE A PHONE NUMBER WHERE YOU CAN BE REACHED:* This field is required.
Area Code
Phone Number
6
EMAIL ADDRESS FOR PARENT COMPLETING THIS FORM:* This field is required..
example@example.com
7
PLEASE PROVIDE THE FULL NAME AND DOB OF THE PATIENT TO RECEIVE A FLU VACCINE:* This field is required.
8
PLEASE PRINT AND COMPLETE THE ATTACHED FORMS AND BRING THEM WITH YOU TO YOUR APPOINTMENT. YOU CAN HOLD OFF ON SIGNING AND DATING UNTIL YOU ARRIVE FOR THE APPOINTMENT.IF YOU ARE UNABLE TO PRINT THIS FORM HERE, DO NOT WORRY, YOU WILL RECEIVE AN EMAIL CONFIRMATION WITH ALL FORMS ATTACHED.
9
Have you read all of the above sections, watched the flu video and printed ALL forms needed for your children to attend the Flu Clinic?* This field is required.REMINDER: IF YOU HAD DIFFICULTY PRINTING THE FORMS HERE, YOU WILL RECEIVE AN EMAILED COPY IN PDF FORMAT UPON COMPLETION OF SCHEDULING BELOW.
YESNO
10
OCTOBER 1, 2022PLEASE SELECT YOUR APPOINTMENT TIME BELOW
Should be Empty: