Just Meds Pharmacy

Flu Clinic Sign Up

Please complete the form below to allow us to get a headcount of what we need at each location. This also allows us to make sure your insurance will cover the immunization(s) requested.

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth

PAYING Relationship Attending

Phone

Email

Insurance Information – RX BIN Number, Processor Control Number (PCN), Cardholder ID, Group Number, Relationship to the Cardholder, or CASH PAYING

Flu Clinic Location Attending

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