Westfield Pediatrics, P.A.

FLU SHOT

Flu Shot Clinic Date:                                                Insurance Company: 

Patient’s Last Name:                                                First Name:

Patient’s Date of Birth:                                             Phone #: 

Child’s Doctor:                        

Does your child have an egg allergy:            Yes         No

Do you prefer FluMist :                                   Yes         No

Any chronic medical conditions:          

For Office Use Only:  

Fluzone : 0.25 ml            UT4119BA       UT4176BA         

Fluzone: 0.50 ml             UT448AA         UT473AA        UT492AA      UT472AA      UT474AB   

FluMist                          501086P           501107P  

Community Plan:            Fluzone 0.25 ml    UT4196AA

                                      Fluzone 0.50 ml    UT491AB

                                                                                    M.D. initials:______________