St. Luke's Hospital Flu Vaccine Pre-Registration

Thank you for participating in St. Luke's Seasonal Flu Vaccinations and doing your part to keep our community healthy!

About This Event

St. Luke's Hospital will provide seasonal, quadrivalent flu vaccinations. High Dose vaccinations will be available for those age 65 or older upon request. These are single dose, preservative free, vaccines.

Be sure to wear comfortable clothing that will allow the St. Luke's health professional to access your shoulder for the vaccination. Also, be sure to bring your health insurance card AND your state issued identification (i.e. driver's license).

Questions? Contact your company's flu vaccine clinic coordinator.

Patient Information

Legal First Name *

Legal Last Name *

Gender * Male Female

Marital Status *

Maiden Name *

Street Address *

City *

State *

Zip *

Phone Type *

Phone (###-###-####) *

Email *

Last 5 digits of SSN (#####)

Birth Date (mm/dd/yyyy) *

Race *

Ethnicity*

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