Seasonal Flu Vaccine Recommendation Form
Use this form to receive a personalized recommendation for the seasonal flu vaccine. Please answer all questions accurately. This form does not collect sensitive health or government ID information.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Age Group
*
Please Select
Under 18
18-49
50-64
65 or older
Have you received a flu vaccine in the past year?
*
Yes
No
Not sure
Do you have any known allergies to vaccines or vaccine components?
*
No
Yes (please specify below)
If yes, please specify your allergies.
Are you currently experiencing any of the following symptoms? (Select all that apply)
*
Fever
Cough
Shortness of breath
None of the above
Do you have any of the following conditions? (Select all that apply)
*
Pregnant
Chronic respiratory condition (e.g., asthma)
Weakened immune system
None of the above
Would you like to receive a personalized seasonal flu vaccine recommendation?
*
Yes
No
Get Recommendation
Should be Empty: