Flu Vaccination | Leading English-speaking Clinic in Budapest

How many people are you scheduling vaccinations for?

Name(Required)

First Last

Date of birth(Required)

Phone(Required)

Email(Required)

Are you currently a FirstMed Premium Plan holder?(Required)

Yes

Have you ever been a patient in FirstMed?(Required)

Yes

Can we find you as a previously registered patient?

Name of second patient(Required)

First Last

Date of birth for second patient(Required)

Does this patient have a Premium Plan?(Required)

Yes

Has this person been a patient in FirstMed at any time?(Required)

Yes

Can we find them as a previously registered patient?

Name of third patient(Required)

First Last

Date of birth for third patient(Required)

Does this patient have a Premium Plan?(Required)

Yes

Has this person been a patient in FirstMed at any time?(Required)

Yes

Can we find them as a previously registered patient?

Name of fourth patient(Required)

First Last

Date of birth of fourth patient(Required)

Does this patient have a Premium Plan?(Required)

Yes

Has this person been a patient in FirstMed at any time?(Required)

Yes

Can we find them as a previously registered patient?

Name of fifth patient(Required)

First Last

Date of birth for fifth patient(Required)

Does this patient have a Premium Plan?(Required)

Yes

Has this person been a patient in FirstMed at any time?(Required)

Yes

Can we find them as a previously registered patient?

Do you (or anyone in your group) have any of the following risk factors?(Required)

Allergy to eggs, chicken, neomycin or formaldehyde

Currently ill

History of bad reaction to the flu shot

History of Guillain Barre Syndrome

None of these

If you check yes to having any of these risk factors we won't be able to vaccinate you.

Which group member?(Required)

Are you (or is anyone in your group) currently:(Required)

Pregnant

Nursing a baby

Diagnosed with any kind of immunodeficiency

Taking any blood thinners

No, none of these

If you check yes to any of these you will need to speak to a doctor before your vaccination.

Which group member?(Required)

Have you received, or are you expecting to receive, any vaccination in the last/next two weeks (including any type of COVID vaccination)?(Required)

Yes

Please list type and date of vaccination:(Required)

Flu Vaccination Request

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