Town of Northborough, MA - H1N1 Registration for High Risk Populations

H1N1 Registration for High Risk Populations


	In anticipation of receiving additional H1N1 vaccine, the Northborough Health Department is gathering the following information to target high risk populations for vaccination with H1N1 vaccine once it becomes available to us. Please submit this form if you are interested in being added to a list for consideration of the vaccine. Please note: At this time this request is appropriate for persons 6 months to 64 years of age. Submittal of this registration is not a guarantee that you will receive the vaccine. Vaccination scheduling is subject to vaccine availability. When vaccine becomes available for your risk group you will be contacted by this office either via phone or email so please list both. It is in your best interest to contact your primary care physician to inquire about receiving the vaccine at his/her office in addition to filling out this registration.

H1N1 Registration for High Risk Population

Field Description	Field Data	Required Field
Choose One:		required

Please describe high risk health condition: (Please fill out a separate form for each person you wish to register):

Field Data

Please provide the following information:

Field Description	Field Data	Required Field
Name:		required
Email Address:		required
Address:		required
City:		required
Name of High Risk Individual		required
Age of High Risk Individual		required
High Risk Health Condition:		required
Phone:		required

Confirmation receipt will be sent within two business days. PLEASE NOTE: THIS REGISTRATION IS FOR NORTHBOROUGH RESIDENTS ONLY. If you are not a Northborough resident please contact the local health department in the Town that you live in.

Northborough Town Hall 63 Main Street, Northborough, MA 01532

Hours -- Mon, Wed, Thu 8am-4pm Tue 8am-7pm Fri 7am-12pm

Virtual Towns & Schools Website Website Disclaimer