Flu Shot Clinic Pre-registration Form

What to Bring

You must present a picture ID and your insurance card at the time of service. Clients are advised to contact their insurance company to determine which Immunizations are covered at the Saginaw County Health Department.

  • Individuals who have no insurance coverage or limited insurance coverage (that which does not cover shots) will qualify to receive the flu vaccine for the administration fee of $20.00. Inability to pay will not defer services.

Notice of Privacy Practices

By filling out this form, I consent to the administration of the flu vaccine to me or to the person for whom I am authorized to make this request. I am aware of the Notice of Privacy Practices containing my rights and the Health Department responsibilities with regard to my protected health information. Vaccinations given and recorded on the clinic record can be released to the Michigan Care Improvement Registry (MCIR) and my insurance plan, if applicable. I authorize the Saginaw County Health Department  to bill and collect from my insurance for the vaccine and associated administration fee.  I verify that all the above information is correct to the best of my knowledge.