COUNTY Please complete the form below and bring to the flu clinic SANDERS For any questions please call the Sanders County Health Department at 406-827-6931. MONTANA Please wear appropriate clothing (short sleeve shirts) to allow access to arm. WASH YOUR HANDS, COVER YOUR COUGH, I give my permission to receive a flu vaccine from the Sanders County Public Health Department. and GET YOUR FLU SHOT! Sanders County Public Health Department "Drive Thru" Flu Clinic schedule - Name: Date of birth: All ages welcome! Mailing Address: SENIOR CENTER CLINIC SCHEDULE DRIVE THRU CLINIC SCHEDULE Phone number: PLAINS SENIOR CENTER 205 Meany St October 13 10 am 12 pm NOXON Ambulance Barn (Railroad Rd) October 6h 10 am -12 pm Signature: Date: Insurance/health coverage information. Medicare # THOMPSON FALLS SENIOR CENTER 1191 Mnt Silcox Dr October 14 3 pm - 5:30 pm Medicare Supplemental Insurance name: TROUT CREEK Fire Station Hall (Trout Creek park) October 6h 3 pm - 6 pm - Member ID # TROUT CREEK SENIOR CENTER Health Insurance Company (BlueCross BlueShield, Allegiance, Tricare, United Health Care, etc) 18 Larch St October 19th 4:30 pm 6:00 pm THOMPSON FALLS Community Center (410 Golf St) October 13th 3 pm - 6 pm Name: Member #: Group #: HOT SPRINGS SENIOR CENTER 101 Main St October 20 11:30 am - 1:30 pm Company contact Phone #: PLAINS Fairgrounds (30 River Road W) October 20h 3 pm - 6 pm Medicaid (HMK PIlus) Member ID# - Do not have health insurance coverage NOXON SENIOR CENTER 207 2nd St October 25 4:30 pm - 6:00 pm HOT SPRINGS Main Stree (behind Spring Street Auto) October 27h 11 am - 1 pm I authorize the Sanders County Public Health Department to enter my flu vaccine into the Immunization Information System (IIS). The IIS is a confidential, computer system that contains immunization records that medical facilities/ HERON SENIOR CENTER 27 Railroad Ave October 27 4:30 pm - 6:00 pm providers will be able to see. Signature: DIXON SENIOR CENTER 106 3rd St November 10 4:00 pm 5:30 pm Date: COUNTY Please complete the form below and bring to the flu clinic SANDERS For any questions please call the Sanders County Health Department at 406-827-6931. MONTANA Please wear appropriate clothing (short sleeve shirts) to allow access to arm. WASH YOUR HANDS, COVER YOUR COUGH, I give my permission to receive a flu vaccine from the Sanders County Public Health Department. and GET YOUR FLU SHOT! Sanders County Public Health Department "Drive Thru" Flu Clinic schedule - Name: Date of birth: All ages welcome! Mailing Address: SENIOR CENTER CLINIC SCHEDULE DRIVE THRU CLINIC SCHEDULE Phone number: PLAINS SENIOR CENTER 205 Meany St October 13 10 am 12 pm NOXON Ambulance Barn (Railroad Rd) October 6h 10 am -12 pm Signature: Date: Insurance/health coverage information. Medicare # THOMPSON FALLS SENIOR CENTER 1191 Mnt Silcox Dr October 14 3 pm - 5:30 pm Medicare Supplemental Insurance name: TROUT CREEK Fire Station Hall (Trout Creek park) October 6h 3 pm - 6 pm - Member ID # TROUT CREEK SENIOR CENTER Health Insurance Company (BlueCross BlueShield, Allegiance, Tricare, United Health Care, etc) 18 Larch St October 19th 4:30 pm 6:00 pm THOMPSON FALLS Community Center (410 Golf St) October 13th 3 pm - 6 pm Name: Member #: Group #: HOT SPRINGS SENIOR CENTER 101 Main St October 20 11:30 am - 1:30 pm Company contact Phone #: PLAINS Fairgrounds (30 River Road W) October 20h 3 pm - 6 pm Medicaid (HMK PIlus) Member ID# - Do not have health insurance coverage NOXON SENIOR CENTER 207 2nd St October 25 4:30 pm - 6:00 pm HOT SPRINGS Main Stree (behind Spring Street Auto) October 27h 11 am - 1 pm I authorize the Sanders County Public Health Department to enter my flu vaccine into the Immunization Information System (IIS). The IIS is a confidential, computer system that contains immunization records that medical facilities/ HERON SENIOR CENTER 27 Railroad Ave October 27 4:30 pm - 6:00 pm providers will be able to see. Signature: DIXON SENIOR CENTER 106 3rd St November 10 4:00 pm 5:30 pm Date: