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H1N1 Vaccine Pre−Registration Form

Instructions


On this form,  HEALTH CARE PROVIDERS  may pre−register to receive H1N1 influenza vaccine when it becomes available through the District of Columbia Department of Health and the Centers for Disease Control and Prevention.


Facilities with multiple locations should submit a separate pre−registration form for EACH vaccination site, unless otherwise approved in advance. Fields with red asterisks are required. You are encouraged to print a copy of this completed form before its submission. Hit the "SUBMIT" button at the end to finish the pre−registration.
 

Type of site being pre−registered
Contact information of the site being pre−registered
Prescriber's Medical License
District of Columbia VFC Provider
How many doses of H1N1 vaccine are estimated to be given at this site?
Estimate the number of vaccinations that might be provide to the following:-

Print this pre−registration form!


It is highly recommended that you print a copy of this completed form BEFORE you click on "SUBMIT". You will not be able to print a copy after submission. Retain a copy of this form for your records.

Thank you!  To finish this pre−registration, click "SUBMIT". You will be redirected to the DC DOH H1N1 webpage for additional information.

 

 

 

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