The IMUnization Clinic - Be Wise, Get IMUnized!
Appointment Request Form
for the
IMU Southwest Office
 
Please remember to include your email address and phone number for confirmation.  Our offices are closed on Sundays and all major Holidays.  After submitting your appointment request, please visit our "FORMS" page to pre-print and complete your consent forms prior to your appointment, if this is will be your first visit with us.  
  Thank you.
 
What day would you like to schedule an appointment?
What time will be most convenient for you?
Hours
 
 : 
Minutes
 
At which facility would you like to schedule your appointment?
Is this appointment for more than 1 person?
No
Yes - 2 people
Yes - 3 people
Yes - 4 people
Yes - 5 or more people
What immunization and/or services will you be receiving?
Routine Child[ren] Immunizatons
Hepatitis A - Adult
Hepatitis B - Adult
HPV Cervical Cancer Vaccine - Adult
IPV [Polio] Vaccine - Adult
Japanese Encephalitis Vaccine - Adult
Meningococcal [Meningitis] Vaccine - Adult
MMR Vaccine - Adult
Pneumonia Vaccine
Other [not listed]
Rabies Vaccine
Shingles Vaccine
Td/Tdap Vaccine - Adult
Typhoid [injectable] Vaccine
Typhoid [oral pills] Vaccine
Varicella [Chicken Pox] Vaccine - Adult
Yellow Fever Vaccine
Lab - Titer Testing for Immunity Verification
Confidential HIV Testing
Urine Drug Screen
First and Last Name
Phone number you can be reached at:
Email Address:
Are you requesting Immunizations for International Travel?
Yes
No
If yes, what is your departure date?
What is your return date?
Where are you traveling to?:
What is the purpose of your trip?
Additional Information/Comments
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