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Date:___Office Use Only: AVP/AFC PRIVATE HIGH Dustcart #: ___MCD FLU & COVID-19 Vaccination Form Patient Legal Name: ___Date of Birth: ___Age:___ Address: ___City: ___State:___Zip:___ Phone: ___ Gender:

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Gather necessary information such as personal details and medical history

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Specify if you have had any recent symptoms or exposure to COVID-19

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Submit the completed forms to the Montgomery County Health Department

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Individuals who want to receive flu and COVID vaccinations from the Montgomery County Health Department

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mchd flu amp covid refers to the reporting requirements for flu and COVID cases implemented by the Montgomery County Health Department.

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Healthcare providers, hospitals, and testing facilities are required to file mchd flu amp covid.

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Information such as patient demographics, test results, and symptoms must be reported on mchd flu amp covid.

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