.	Patient Full Name
	Patient Address.
	City / State / Zip .
	Medicare Part B #.	D.O.B. (mm-dd-yy)
	Sex.	Billing Date.
	.	.
	Make a Vaccine and Admin Claim ?. ..YES .
	Pick just one per patient:
	. . . Afluia vacc.	. . . Flulaval vacc.
	. . . Fluvirin vacc.	. . . Fluzone vacc.
	.	.
	PLUS: we will add a dispensing fee for each shot given.
	.
	(when you click the FINISH button below, that's all we need ! )

This box is for messages. If other than a FLU SHOT, identify what kind of shot was given in this field.

text entry area

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