HIGHTSTOWN MEDICAL ASSOCIATES

Flu Vaccine Signup Form

The New Flu Vaccine Registration System is up and running!

We are hoping to receive our shipment of Influenza Vaccine in September. If you would like to be notified when the vaccine arrives, please complete and submit the form below. We will add you to the Flu Vaccine Notification List.

Once we receive the vaccine, we will send a broadcast email to all those patients who have signed up. Please understand that this does not obligate you to receive the vaccine and this does not guarantee that you will be able to receive the vaccine. After you receive the email, you must call us and schedule an appointment for the vaccine. It will be given on a first scheduled basis, so you must call before it is gone. We apologize for this inconvenience. We expect to have enough so that all of our patients may be covered, but there is no guarantee. No shortage is expected this year. We will keep you informed as developments unfold.

In the form below, please fill in all fields. Please verify the spelling of your email address. SUBMIT the form when complete. You will receive a confirmation email. If you do not, then return here and repeat this process (you might have typed your email address incorrectly).

Would you like to: Register an Email address or
Delete an Email address?
 
Your First Name:
Your Last Name:
Your Phone #:
Email Address:
Re-enter Email:
Primary Physician:
Please tell us how many family members would like flu vaccine this year. (If you create a second registration so that you receive notice at more than one email address, please select zero family members for all secondary emails so that we do not double count you.) (If some family members are high risk, some not, please create two entries, one for the high risk members, another for the non-high risk.)
# Family Members:
In the case of another vaccine shortage, we are required to identify those patients who are considered high risk for the flu and to vaccinate those patients first. You are considered high risk if any of the following apply to you:
  Age 65+ Diabetes Mellitus Heart Disease Asthmatic
  Pregnant Kidney Disease Lung Disease Healthcare Workers
  Care for infants (<6 months old) or the elderly Nursing Home or Assisted Living Residents
Can you be considered High Risk?      Yes     No
Please select a notification frequency:
(New this year)
 One-Time We will only contact you this year
Perpetual We will contact you every year until you tell us to stop