Health Care Professionals HCP Forms 2025-2026 Flu Season OPT-IN Form Please fill out and submit prior to Friday, September 12.Name of Practice(Required)Office Contact Person(Required)Phone(Required)Fax(Required)Will you provide flu vaccine to your patients this year?(Required) YES, I would like to provide flu vaccine this year NO, I will not be providing flu vaccine this year How do you plan to offer flu vaccines to your patients this year?(Required) Regular appointment-based only Flu clinics only (on or after November 1st) Both regular appointment-based and flu clinics Planned Clinic Date(s) if known:Approximately how many of your patients will require ”Regular" Quadrivalent flu vaccines?(Required)Approximately how many of your patients will require High-Dose Trivalent or Quadrivalent flu vaccine?(Required)Approximately how many patients in your practice have a thimerosal allergy who regularly receive the flu vaccine?(Required)