If getting Flu Vaccine ONLY, you can fill out questions 1-4 only, otherwise all questions need to be answered for any other vaccine
Skip 5-11 if ONLY getting FLU Vaccine
1. Type BENECARD ID# if applicabletype ID# 2.On your HORIZON as Medical Insurance, please enter the ID Number on your card type ID# 3.Who is the Primary Cardholder?first name/ last name
After pressing SUBMIT, you are finished and will be redirected to a GOOGLE REVIEW page, and if you entered an email, will receive a copy of the Pre-Vaccination Checklist for your records.