JCPH Drive-thru Flu Vaccine Clinic

1
Enter from SW Woods Chapel Rd and turn west into the parking lot of First United Methodist Church of Blue Springs. You will remain in your vehicle during the entire appointment.
2
Use the picker to choose your appointment time.* This field is required.Please note: you may be asked to wait for a 15-minute observation period after receiving your vaccine(s).
3
Would you like to receive appointment reminders via text message?* This field is required.
YESNO
4
Patient Name* This field is required.
First Name
Middle Name
Last Name
Suffix
5
If you have a different preferred name, please list that below:
6
Date of Birth* This field is required.
Date
Month
Day
Year
7
How old will the patient be at the time of the clinic?* This field is required.
6 months - 11 years old
12 - 17 years old
18 - 64 years old
65 years old +
8
Place of Birth (State/Country)* This field is required.
9
Race (Choose all that apply)* This field is required.
White / Caucasian
Black / African-American
Asian
Native Hawaiian / Pacific Islander
American Indian / Alaska Native
Prefer not to answer
Other
10
Ethnicity* This field is required.
Hispanic / Latino
Not Hispanic or Latino
Prefer not to answer
11
Birth Sex* This field is required.
Male
Female
Unknown
12
Gender* This field is required.
Male
Female
Indeterminate
Unknown
Other
13
Address* This field is required.
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
14
Phone Number* This field is required.
Area Code
Phone Number
15
Will the patient or guardian require interpreter services?* This field is required.
YESNO
16
Preferred Language, if other than English
17
Email* This field is required.This will be used for an appointment confirmation.
example@example.com
18
Does the patient have a responsible party who will need to authorize vaccination on their behalf?* This field is required.
YESNO
19
Name* This field is required.
First Name
Middle Name
Last Name
20
Date of Birth* This field is required.
Date
Month
Day
Year
21
Relationship to Patient* This field is required.
22
Are the phone number and address for the responsible party the same as for the patient?* This field is required.
YESNO
23
Phone Number* This field is required.
Area Code
Phone Number
24
Address* This field is required.
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
25
Name* This field is required.
First Name
Last Name
26
Phone Number* This field is required.
Area Code
Phone Number
27
Relationship to the Patient* This field is required.
28
Are you feeling sick today?* This field is required.
YESNO
29
Are you moderately or severely immunocompromised?* This field is required.
YESNO
30
Do you have a food, medication or vaccine allergy?* This field is required.
YESNO
31
You answered "yes" to having a food, medication or vaccine allergy. Please describe:* This field is required.
Huge
Large
Normal
Small
Ok
Ok
32
Have you ever had a severe reaction to a vaccine or medication?* This field is required.
YESNO
33
You answered "yes" to having a history of severe reaction to a vaccine or medication. Please describe:* This field is required.
Huge
Large
Normal
Small
Ok
Ok
34
Have you ever had a seizure or convulsion?* This field is required.
YESNO
35
Have you received a flu shot yet this season?* This field is required.
YESNO
36
For those over 65 years old or immunocompromised, we are offering Flublock. This is a higher-dose flu shot recommended for extra protection. Would you like to receive Flublock instead of a standard-dose influenza?* This field is required.
YESNO
37
Please select your insurance status* This field is required.We will not be billing your insurance. This is only for data collection purposes.
I have insurance that covers vaccines.
I do not have insurance or my insurance does not cover vaccines.
38
Flu Vaccine Authorization & Consent

You are being offered the influenza vaccine (2025-2026 formula). Vaccine Information Sheet (VIS) contains information to help you understand the risks and benefits of the vaccine. The VIS may have been updated. For the most recent VIS, please see https://www.immunize.org/vis/flu_inactive.pdf.

If you have questions about this vaccine, please call our nurse line at 816-404-6456.

Your signature indicates the following: I have been given a copy and have read, or have had explained to me, the information in the Vaccine Information Sheet for influenza. After being educated on the risks and benefits, I hereby consent to be inoculated with the influenza vaccine. I have had a chance to ask questions that were answered to my satisfaction.
39
Flu Vaccine Authorization & Consent* This field is required.
Clear
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Jackson County Health Department is managed and operated by Truman Medical Centers. The notice of privacy practices can be found here: https://res.cloudinary.com/dpmykpsih/image/upload/truman-site-261/media/a9e26969dc2448bfa6552be9f828a139/uh_notice-of-privacy-practices_poster_2021.pdf

My signature indicates that I have reviewed a copy of the Notice of Privacy Policy.
41
Signature of Patient or Legal Guardian* This field is required.
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