Flu shot clinic registration - Delanco Township, New Jersey

10/25/2024 FLU SHOT CLINIC REGISTRATION

ONE REGISTRATION PER PERSON. PLEASE ONLY FILL ONE FORM OUT PER PERSON ATTENDING THE CLINIC.

FIRST NAME

LAST NAME

Email Address

INSURANCE COVERAGE OR OUT OF POCKET PAYMENT

INSURANCE
OUT OF POCKET PAYMENT (cash or credit/debit card payment accepted) $55.99 13-64; $113.99 Hi-Dose vaccination 65 years or older)

PLEASE PRINT, COMPLETE AND BRING THE PARAMOUNT CONSENT AND AUTHORIZATION FORM FOUND ON THE MAIN SCREEN WITH YOU THE DAY OF THE EVENT.