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South City Health Expo Vaccine Registration
Please fill out this form to register for a flu shot or Hepatitis A vaccine for the South City Health Expo on 12/12/2020 at 524 Orange Avenue from 9:30am - 12:00pm.
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* Indicates required question
Name
*
Your answer
Best Contact (phone number or email)
*
Your answer
Select the vaccine you would like to receive (select one or both):
*
Flu Shot
Hepatitis A Vaccine
Required
Would you like to speak with someone about ACA Open Enrollment?
*
Yes
No
Where do you usually go for health care treatment?
*
Neighborhood Medical Center
Bond Community Health Center
Patients First
TMH Emergency Room
CRMC Emergency Room
Other
Do you have children who need a flu shot? If so, how many?
*
Not applicable
1
2
3
4
5+
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