In-store FLU Shots
Registration
FLU (seasonal 2022) Vaccine
Flucelvax Quadrivalent for UNDER 65 years of age
or
FLUAD+65 Quadrivalent for OVER 65 years of age
IMPORTANT:
This form is ONLY for people who wish to register for:
a 2022 Flu Shot
Completing this form will allow you to schedule a seasonal FLU VACCINE appointment to receive:
Flucelvax or Afluria Quadrivalent vaccine (under 65 years)
or
FLUAD +65 Quadrivalent vaccine (over 65 years)
from staff of:
Fairmount Pharmacy
at
1900 Green Street
Philadelphia, PA, 19130
PLEASE BRING YOUR INSURANCE CARD AND ID.
PLEASE WEAR SHORT SLEEVES FOR EASE OF ACCESS TO INJECTION SITE.
We look forward to seeing you!