FLU SHOT CLINIC IN-TAKE FORM

OCT. 24

Please use the following form to sign-up for the clinic held on October 24. 

Once completed, you will be able to choose a time slot.

Gender
Allergies?
Are you filing this flu shot on your insurance?

HOURS:

Mon. - Fri.   9:00am - 6:00pm

Sat.              9:00am - 1:00pm

Sun.             CLOSED

Piedmont Pharmacy & Gifts

97 Gooder Simpson Blvd.

Piedmont, OK 73078

Ph:  405.373.3090  /  Fax: 405.373.1748

piedmontrx@gmail.com