Taconic Hills Central School Flu Clinic - Thursday, October 5, 2023
IMPORTANT INSTRUCTIONS THE FLU CLINIC, PLEASE READ:  Please complete the screening tool below to pre-register for the flu shot at Taconic Hills Central School on Thursday, October 5, 2023 from 2:30 p.m. - 3:30 p.m..  Please provide a telephone number where you can be reached so that we may contact you for further information if needed.  If you have an e-mail address, we will e-mail you your confirmation of pre-registration.  If you believe you have successfully registered but have not received an email confirmation within 5 business days, please contact the Health Department by phone or by email to ccdoh@columbiacountyny.com.

If you are sick with any symptoms associated with flu or COVID-19 illness (fever, shortness of breath or difficulty breathing, sore throat, chills, new loss of taste of smell, or extreme headache) please DO NOT come to the drive-thru clinic; please call your primary care doctor or call our office at 518-828-3358 for further guidance.

Pre-registration is required to receive your flu shot on this date.  If you do not register ahead of time,  you can not be vaccinated at this flu clinic.  If you are registering for someone else (e.g. spouse or child), a separate registration form must be completed for each individual.  Photo ID is required for each person vaccinated.

Please note: WE Now offer the high dose (senior) flu vaccination for those that are eligible.

If you do not have email but would like to register, please enter none@none.com, or call the Health Department at (518) 828-3358.
E-mail *
If you do not have E-Mail, but still want to register enter none@none.com
First Name *
Last Name *
Date Of Birth (Ex. 01/01/2011) *
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MM
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I am over the age of 65, and would like to receive the high dose (senior flu) shot.

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Gender *
Telephone Number  - including area code
(Ex 518-828-3358)
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Mailing address *
City/Town *
State *
Zip Code *
Name of Primary Care Doctor or Medical Practice
Have you ever recieved a flu shot? *
Have you ever had a severe reaction to a flu shot in the past, including but not limited to Guillain Barré syndrome? (If yes, we CANNOT allow you to come to our clinic).  Please contact your doctor for further guidance).
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Do you have any allergies? *
If you have allergies, please check all that apply:
If you checked "other" above, please list your allergies below:
Are you currently pregnant or breastfeeding?
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Do you have Health Insurance? *
Primary Insurance (select N/A if not insured or your insurer is not listed below).
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Member ID/Subscriber ID (not Group #) *
Do you have a secondary insurance? *
If yes, List Insurance Company Name and Member ID Number/Subscriber ID (not Group #)
If you are over the age of 19, the Health Department is required to have permission to enter your immunization into the NYS Immunization Database (NYSIIS).  Entering your information will allow yourself and your physician to have access to this record.  Please indicate below whether or not you consent.
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You must check the box below to provide voluntary consent to receive the influenza vaccination from the Columbia County Department of Health.  By checking this box, you are also agreeing to allow CCDOH to bill your insurance, and acknowledging that you will receive/have access to a copy of the Patient of Bill of Rights, Notice of Privacy, and the Vaccine Information Statement on the date of administration of the vaccine.
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