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Armin Jahr Elementary School Flu Vaccine Registration
Please fill out the questions below to register for an appointment with us to get your flu shot!
Are you new to PCHS?
Yes
No
Patient Information
Patient's Name
*
First Name
Last Name
Patient's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient's Sex at Birth
*
Male
Female
Patient's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Contact Information
Please provide your contact details so we can reach you regarding your appointment.
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Do you consent to call?
*
Yes
No
Do you have insurance?
*
Yes
No
Would you like to be contacted about how to apply for Sliding Scale or have a Navigator contact you?
*
Yes
No
Back
Next
Insurance Information
Please provide your insurance information to help make your appointment
Primary Insurance Name
*
ID Number
*
Guarantor (person who is responsible for the insurance)
*
First Name
Last Name
Guarantor's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Insurance Address (address on the back of the card)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Would you like to add a secondary insurance?
*
Yes
No
Back
Next
Secondary Insurance Information
Secondary Insurance Name
*
ID Number
*
Guarantor (person who is responsible for the insurance)
*
First Name
Last Name
Guarantor's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Insurance Address (address on the back of the card)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Submit
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