Please complete the screening information below, then press the “Next” button at the bottom of the page for a printable voucher.
District of Columbia
Date of Birth:
Has this person had a serious reaction to the flu vaccine in the past?
Has this person had cardiac arrest, collapsed or called 911 after receiving this vaccine in the past?
Does this person have an allergy to eggs or egg products?
Has this person had a reaction to eggs involving symptoms other than hives, such as angioedema, respiratory distress, lightheadedness, or recurrent emesis; or who required epinephrine or another emergency medical intervention?”
Has this person ever had Guillain-Barre Syndrome (GBS)?
Has this person had a history of GBS within six weeks after having a previous vaccination?
Is this person allergic to Thimerosal or mercury products?
Has this person experienced respiratory distress or collapsed after using products containing Thimerosal?
By checking the "Agree" box, I acknowledge that I have been offered a copy of the
Vaccine Information Statements
(Inactivated/Recombinant and Live, Attenuated) and I consent for the vaccine to be given to me or the person named above for whom I am authorized to sign. If there are any questions, please contact your local Health Department.
After completing the screening information, press the “Next” button for a printable voucher.