Can not connect Flu Clinic Registration System
Town of Westford Seal
Town of Westford
Health Department
55 Main Street
Westford, MA 01886
978-692-5500
Flu Clinic Registration System
 

Please complete the following form and clink the submit button below.

All sections must be completed, and a separate registration must be completed for each student


NOTE: If you are experiencing problems navigating to the next section, please try the alternate form

Student Information
Note: all questions marked with a "*" are required:

Insurance Information

Is your child covered by insurance?
Subscriber's Information
 
Note: all questions marked with a "*" are required:

Screening Questions

  1. Has your child ever received a flu vaccination?
  1. Is your child allergic to eggs or egg protein, or thimerosal?
  1. Has your child ever had Guillain-Barre syndrome?
  1. Has your child ever had a life threatening reaction to flu vaccine?
Note: all questions must be answered:

Parent Contact Information

I have Read and Understand the information contained in the Vaccine Information Statement (VIS).
I have Read and Understand the information contained in the MIIS Fact Sheet (MIIS).
Note: To limit who can see your information, you need to fill out the
MIIS Objection (or Withdrawal of Objection) Form
 
Note: all questions must be answered: