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Flu Vaccinations – Step 1

I have had a prior allergic reaction after a dose of seasonal influenza vaccineI have had Guillain Barre SyndromeI am currently moderately or severely sickI have a severe allergy to (eggs, egg protein, gentamicin, gelatin, arginine, latex, formaldehyde, neomycin, thimerosal, polymyxin)I have a problem with my immune system (i.e. cancer, HIV/AIDS, etc.)I am 18 years old or younger (Only check if scheduling for the Lilburn Activity Building Drive Thru and you are 18 and under)

Please read the HIPAA Notice of Privacy Policy
Received the Gwinnett, Newton, or Rockdale HIPAA NOTICE of Privacy Policy

Please read the Vaccine Information Statement
I read and understand the VACCINE INFORMATION STATEMENT and understand the benefits and risks of the influenza vaccine.

I agree to remain onsite for 15 minutes after the vaccine is administered to be monitored for adverse reactions.

Full Name:


Sorry, you are currently not eligible to receive a flu shot.