Flu Clinic

Event Date: 
Tuesday, October 18, 2011 - 2:30pm - 5:30pm
Location:Traci Arledge
Event Type:
General

Passport Health will be in the SCA Fellowship Hall on Tuesday, October 18, 2011 from 2:30-5:30pm for our Flu Clinic.  This clinic is open to all students, their families and the staff at FBNS. We will have flu shots, preservative free flu shots, flu mist (nasal spray) and pneumonia vaccinations available. The pandemic strain of H1N1 is included in the 2011-12 seasonal flu vaccine, so only one shot is necessary.

 

·         Flu Shot- $25

·         Preservative Free Flu Shot- $30

·         Flu Mist (nasal spray)- $45

·         Pneumonia Vaccine- $75

 

**** See payment options at the bottom of form

If you and your family would like to participate, please fill out the information below and return to school with your student no later than October 4th.   You must be signed up to participate.   If you have any questions please contact Leigh Ann Skipper at lskipper@fbns.org or 578-4238 Ext. 4200. 

 

Please list name and age of each participant and please indicate (x) vaccine desired:

                           

______________________________Age____ Shot____Preserv. Free shot____Mist____

 

______________________________Age____ Shot____Preserv. Free shot____Mist____

 

______________________________Age____ Shot____Preserv. Free shot____Mist____

 

______________________________Age____ Shot____Preserv. Free shot____Mist____

 

______________________________Age____ Shot____Preserv. Free shot____Mist____

 

Pneumonia Vaccine (recommended for anyone over age 65 or as directed by a physician)

 

Name: ______________________________Age_______

 

Name: ______________________________Age_______

 

 

Please Mark how you will be paying the day of the flu clinic:

 

_____ Cash         _____ Check          _____ Credit Card

 

 

*Form must be returned to your child’s teacher no later than October 4th!

 

 

***Payment will be accepted in the form of cash, check or credit card at the time of service.  All checks need to be made to Passport Health and will go directly to Passport Health on October 18th.  Please DO NOT send payment with this form.

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