GIHW Flu 2021 Patient Registration
Thank you for expressing interest in receiving your influenza vaccination with the Global Initiative for Health and Wellness and Samaritan House of San Mateo.

Our clinic is located at 19 W 39th Ave. Ste. #5, San Mateo, CA 94403. This is NOT the main Samaritan House location where food distribution is given, but a few blocks north on El Camino Real. For directions, click here: https://goo.gl/maps/Tb8dk261vwwuo5ib6

You will receive an email with a copy of your responses to this form. This email should also contain a link where you can edit your response, if you need to change your appointment date or time. By providing us with an accurate count of patients who will be visiting us each day, you ensure that we are able to maintain enough doses for all those wishing to get vaccinated with us, and that no dose goes to waste after being prepared.

For more information on our clinic, please visit https://www.gihw.org/e/flu2021.

The flu vaccine is provided to us by San Mateo County Health. No ID nor proof of insurance is required, this program is completely free and open to the public.

San Mateo County Health uses a secure computer system (the California Immunization Registry, a
Zblso known as CAIR) to enter patient’s immunizations. The flu vaccine that you or your child receives will be entered in the system. The information can be viewed by other physicians, clinics and schools who have permission to use the Registry.
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Email *
Your First Name *
Your Last Name *
Appointment Date *
List of Patients, one full name per line *
Press ENTER to add a new line. This list will be used to clarify spelling if we are unable to read your signed forms. The correct spelling of your name is needed to properly enter your information into the immunization registry.
Note
PLEASE READ THIS SECTION CAREFULLY: Children less than 6 months old are ineligible for the flu vaccine.
Total number of patients taking the vaccine *
Number of patients who are (1) pregnant OR (2) age 6month-3years old *
A copy of your responses will be emailed to the address you provided.
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