H1N1 Provider Registration

H1N1 Provider Registration
If you have any questions regarding this registration process, please contact us either by Phone: (407) 943-7035 or Email: H1N1Questions@doh.state.fl.us
Health Care Provider Name:
Address:
City:
Phone Number:
Fax Number:
Email:
Contact Person:
Current Medical License Number:
VFC Pin#, MPI and EMR if applicable:
Are you a part of a medical group?	Yes No
If you answered yes that you are part of a medical group, what is the name of the medical group?
Enter the approximate number of patients that you will be vacinating in the following priority groups	Pregnant Women People who care for or live with children younger than 6 months of age Health care workers (Provides direct care to patients) and emergency medical services personnel Patients 6 months through 24 years of age Patients aged 25 through 64 years with health conditions associated with a higher risk of medical complications with the flu
Can your office's nursing staff administer the vaccine to your patient panel? Yes No
Can your office's nursing staff administer the vaccine to your staff? Yes No
Do you have space to store vaccine? (refrigeration for vaccine is mandatory) Yes No
Can your staff arrange to pick up the vaccine from a central location? Yes No
Are you registered in Florida Shots? Yes No

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