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On this form, HEALTH CARE PROVIDERS may pre−register to receive H1N1 influenza vaccine when it becomes available through the District of Columbia Department of Health and the Centers for Disease Control and Prevention.

Facilities with multiple locations should submit a separate pre−registration form for EACH vaccination site, unless otherwise approved in advance. Fields with red asterisks are required. You are encouraged to print a copy of this completed form before its submission. Hit the "SUBMIT" button at the end to finish the pre−registration.