Legal last name
* must provide value
Legal first name
* must provide value
Birth date
* must provide value
Today M-D-Y
Are you 19 or older?
* must provide value
Yes
No
Mailing address
* must provide value
State
* must provide value
Zipcode
* must provide value
Primary phone number
* must provide value
Gender
* must provide value
Female
Male
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Other
Ethnicity
* must provide value
Hispanic/Latino
Not Hispanic/Latino
Has the person to be vaccinated ever experienced severe allergic reactions to the vaccine or any of its components (eggs or egg protein, gentamicin, gelatin, arginine) or to a previous dose of any influenza vaccine?
* must provide value
Yes
No
Don't know
Has the person to be vaccinated ever had Guillain-Barré syndrome?
* must provide value
Yes
No
Don't know
What type of health insurance do you have?
* must provide value
Medicaid
Medicaid HMO
Medicare Part B
FAMIS
Private health insurance
None
Is your insurance plan either Humana Gold Choice Plus PPO/HMO or Humana Health Plan?
* must provide value
Yes
No
Insurance company name
* must provide value
Insurance company address (on back of card. If no address, please put N/A.)
* must provide value
Policy holder
* must provide value
Relationship to policy holder
* must provide value
Child Grandchild Self Spouse Step-child
Policy number
* must provide value
Effective date
* must provide value
Do you have a secondary insurance policy?
* must provide value
Yes
No
What type of secondary health insurance do you have?
* must provide value
Medicaid
Medicaid HMO
Medicare Part B
FAMIS
Private health insurance
Insurance company name
* must provide value
Insurance company address (on back of card)
* must provide value
Policy holder
* must provide value
Relationship to policy holder
* must provide value
Child Grandchild Self Spouse Step-child
Policy number
* must provide value
Effective date
* must provide value
I authorize VDH to release records necessary to support the application for payment by Medicare, Medicaid, and other health care benefits. I request the third party payer to pay any authorized benefits to VDH on my behalf.
* must provide value
Now D-M-Y H:M
Please review the privacy practices document.
RECEIPT OF THE NOTICE OF PRIVACY PRACTICES
I acknowledge that I have read the Notice of Privacy Practices from the Virginia Department of Health.
* must provide value
Now D-M-Y H:M
I authorize VDH to release records necessary to support the application for payment by Medicare, Medicaid, and other health care benefits. I request the third party payer to pay any authorized benefits to VDH on my behalf.
AND
I acknowledge that I have read the Notice of Privacy Practices from the Virginia Department of Health.
AND
I hereby authorize vaccinators working under the direction and supervision of licensed health care providers of the Virginia Department of Health to immunize me or my child named above. I understand the risks and benefits of the immunizations checked below and have had the opportunity to ask questions. I have received VACCINE INFORMATION STATEMENTS or information sheets about the immunizations. I agree that my or my child's immunization record and date of birth may be shared with other health care providers. I understand that this information will be used by health care providers for the care of me or my child. I understand that this information will be kept confidential. The Deemed Consent for blood borne diseases has been explained to me and I understand it. I understand that medical records must be kept for a period of 5 years after my last visit or until age 21, if a minor.
* must provide value
Now D-M-Y H:M
Please review the following document for information about the influenza vaccine.
Please select your locality of residence. After you select your locality of residence, you will see options for scheduling your appointment. If there is more than one school option offered, please select the school where your child attends school. Only select one appointment.
* must provide value
Bland
Bristol
Carroll
Galax
Smyth
Washington
Wythe
Please choose your time for a vaccine. Once all slots are taken, you will not be able to select that option. All appointments are at Bland County High School, 176 Eagles Rd, Rocky Gap, VA 24366.
Thursday 10/22 4:00 - 5:00
Thursday 10/22 5:00 - 6:00
Thursday 10/22 6:00 - 7:00
Please choose your time for a vaccine. Once all slots are taken, you will not be able to select that option. All appointments are at Virginia High School, 1200 Long Crescent Drive, Bristol, VA 24201.
Thursday 10/15 3:00 - 4:00
Thursday 10/15 4:00 - 5:00
Thursday 10/15 5:00 - 6:00
Thursday 10/15 6:00 - 7:00
Please choose your time for a vaccine. Once all slots are taken, you will not be able to select that option. All appointments are at Carroll County Middle School, 1036 N. Main Street, Hillsville, VA 24343.
Thursday 10/15 4:00 - 5:00
Thursday 10/15 5:00 - 6:00
Thursday, 10/15 6:00 - 7:00
Please choose your time for a vaccine. Once all slots are taken, you will not be able to select that option. All appointments are at Galax Elementary School, 225 Academy Dr, Galax, VA 24333.
Monday 10/26 3:30 - 4:00
Monday 10/26 4:00 - 5:00
Monday 10/26 5:00 - 6:00
Monday 10/26 6:00 - 7:00
Please choose your time for a vaccine. Once all slots are taken, you will not be able to select that option. All appointments are at Chilhowie High School, 1160 E Lee Hwy, Chilhowie, VA 24319.
Monday 10/5 3:00 - 4:00 SCHOOL STAFF ONLY
Monday 10/5 4:00 - 5:00
Monday 10/5 5:00 - 6:00
Monday 10/5 6:00 -7:00
Please choose your time for a vaccine. Once all slots are taken, you will not be able to select that option. All appointments are at Marion Senior High School, 848 Stage St, Marion, VA 24354.
Tuesday 10/6 3:00 - 4:00 SCHOOL STAFF ONLY
Tuesday 10/6 4:00 - 5:00
Tuesday 10/6 5:00 - 6:00
Tuesday 10/6 6:00 - 7:00
Please choose your time for a vaccine. Once all slots are taken, you will not be able to select that option. All appointments are at Northwood High School, 305 Panther Ln, Saltville, VA 24370.
Thursday 10/8 3:00 - 4:00 SCHOOL STAFF ONLY
Thursday 10/8 4:00 - 5:00
Thursday 10/8 5:00 - 6:00
Thursday 10/8 6:00 - 7:00
Please choose your time for a vaccine. Once all slots are taken, you will not be able to select that option. All appointments are at Holston High School 21308 Monroe Rd, Damascus, VA 24236.
Tuesday 10/20 2:00 - 3:00
Tuesday 10/20 3:00 - 4:00
Tuesday 10/20 4:00 - 5:00
Tuesday 10/20 5:00 - 6:00
Tuesday 10/20 6:00 - 7:00
Please choose your time for a vaccine. Once all slots are taken, you will not be able to select that option. All appointments are at Patrick Henry High School, 31437 Hillman Hwy, Glade Spring, VA 24340.
Thursday 10/22 2:00 - 3:00
Thursday 10/22 3:00 - 4:00
Thursday 10/22 4:00 - 5:00
Thursday 10/22 5:00 - 6:00
Thursday 10/22 6:00 - 7:00
Please choose your time for a vaccine. Once all slots are taken, you will not be able to select that option. All appointments are at Abingdon High School, 705 Thompson Drive, Abingdon, VA 24210.
Tuesday 10/27 2:00 - 3:00
Tuesday 10/27 3:00 - 4:00
Tuesday 10/27 4:00 - 5:00
Tuesday 10/27 5:00 - 6:00
Tuesday 10/27 6:00 - 7:00
Please choose your time for a vaccine. Once all slots are taken, you will not be able to select that option. All appointments are at John Battle High School, 21264 Battle Hill Drive, Bristol, VA 24202.
Thursday 10/29 2:00 - 3:00
Thursday 10/29 3:00 - 4:00
Thursday 10/29 4:00 - 5:00
Thursday 10/29 5:00 - 6:00
Thursday 10/29 6:00 - 7:00
Please choose your time for a vaccine. Once all slots are taken, you will not be able to select that option. All appointments are at George Wythe High School, 1 Maroon Way, Wytheville, VA 24382.
Monday 10/5 3:00 - 4:00
Monday 10/5 4:00 - 5:00
Monday 10/5 5:00 - 6:00
Monday 10/5 6:00 - 7:00
Please choose your time for a vaccine. Once all slots are taken, you will not be able to select that option. All appointments are at Rural Retreat High School, 321 E Buck Ave, Rural Retreat, VA 24368.
Tuesday 10/6 3:00 - 4:00
Tuesday 10/6 4:00 - 5:00
Tuesday 10/6 5:00 - 6:00
Tuesday 10/6 6:00 - 7:00
Please choose your time for a vaccine. Once all slots are taken, you will not be able to select that option. All appointments are at Fort Chiswell High School, 1 Pioneer Trail, Max Meadows, VA 24360.
Thursday 10/8 3:00 - 4:00
Thursday 10/8 4:00 - 5:00
Thursday 10/8 5:00 - 6:00
Thursday 10/8 6:00 - 7:00
Smyth County Administration - Smyth County Administration Employees ONLY
Friday October 23
Please review all information for accuracy. Clicking the checkmark will submit the survey.