Patient Name
Home Address
Preferred Appointment Date & Time
Have you ever had a severe allergic reaction to a flu vaccine?
Do you have a severe allergy to eggs?
Are you currently feeling sick or have a fever today?
Have you ever had Guillain-Barré syndrome (GBS)?
Insurance / Payment
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Healthcare providers, pharmacies, employers, and public health departments running seasonal flu shot clinics need to register patients, schedule appointments across multiple clinic sites, screen for vaccine eligibility and allergies, and process insurance information.

The Flu Shot Clinic Registration Form Template from WPForms helps clinic coordinators collect patient details, screen medical history, display flu clinic locations on an interactive map with location selection, and gather insurance information in one form.

Exploring the Flu Shot Clinic Registration Form Template

This template works for hospitals, pharmacies, corporate wellness programs, public health departments, urgent care centers, or any organization coordinating seasonal flu vaccination clinics across multiple locations. Here’s what’s included:

  • Patient Name: Captures the patient’s full name for appointment records and vaccination card documentation.
  • Email Address: Provides a contact point for sending appointment confirmations, clinic reminders, insurance verification requests, or vaccination record copies.
  • Phone Number: Gives clinic staff a direct line for appointment coordination, insurance questions, or clinic location changes.
  • Home Address (Address Line 1, City, State, Zip Code): Collects patient address for medical records and follow-up correspondence.
  • Preferred Appointment Date & Time (Date + Time): Lets patients schedule their preferred vaccination appointment so clinics can manage capacity and vaccine inventory.
  • Date of Birth (Date): Verifies patient age for dosage determination and ensures proper vaccine formulation (standard dose vs. high-dose for seniors).
  • Have you ever had a severe allergic reaction to a flu vaccine? (Multiple Choice): Screens for vaccine contraindications to identify patients who may need medical consultation before vaccination.
  • Do you have a severe allergy to eggs? (Multiple Choice): Identifies egg allergy history since some flu vaccines are egg-based, though current CDC guidance allows vaccination under medical supervision.
  • Are you currently feeling sick or have a fever today? (Multiple Choice): Screens current illness status to determine whether vaccination should be postponed.
  • Have you ever had Guillain-Barré syndrome (GBS)? (Multiple Choice): Identifies GBS history since patients with prior GBS may need medical consultation before flu vaccination.
  • Medications, allergies, or medical conditions (optional) (Paragraph Text): Collects relevant medical history, current medications, or conditions that may affect vaccine selection or timing.
  • Insurance / Payment (Multiple Choice): Determines payment method so clinic staff can prepare billing or insurance verification.
  • Insurance Provider (if applicable) (Single Line Text): Captures insurance company name for billing and coverage verification.
  • Choose Flu Shot Clinic (Map Field): Displays multiple flu clinic locations on an interactive map with radio button selection so patients can pick the most convenient site.

Customizing the Map Experience (Geolocation Addon + Map Field)

The Choose Flu Shot Clinic field uses the Map Field to display multiple clinic sites and let patients select their preferred location. It requires WPForms Pro or higher and the Geolocation Addon configured with a valid Google Maps or Mapbox API key.

Without a valid API key, the map won’t render and address autocomplete won’t function. This template is pre-configured with Allow Location Selection enabled, which means:

  • Multiple locations required: You must add 2+ clinic sites using the repeater tool. Each location supports a unique Location Name, Address, and Marker.
  • Show List of Locations is automatically enabled when you turn on Allow Location Selection, displaying location names and addresses beneath the map with radio buttons for patient selection.
  • Zoom behavior: Because this template uses multiple locations, the map auto-fits all markers into view and the zoom dropdown becomes disabled.

Additional Customization Options:

  • Custom markers: Use the Icon Library with color picker for a clean, professional look or upload a custom marker image (useful for distinguishing drive-thru clinics from walk-in sites, or highlighting ADA-accessible entrances).
  • Cleaner map controls: If you want a simpler “pick a clinic” display, you can hide fullscreen, map type, street view, camera control, zoom buttons, or disable dragging and mouse zooming to limit interactions.
  • Nearby bias (optional): “Find Nearby Location” can be enabled to use browser geolocation and bias autocomplete results toward the patient’s area, helping patients identify which clinic location is closest to their home or workplace.

Ready to Register Patients Across Multiple Flu Shot Clinics?

Use this template to collect patient appointments, screen medical eligibility, process insurance details, and let patients choose their preferred flu clinic location on an interactive map. Get WPForms Pro to access the Map field, then customize the screening questions and clinic sites for your vaccination program.