Skip to form

Montgomery County Government OMS/FROMS

OMS.Appt@montgomerycountymd.gov

27 Courthouse Square, Suite 180 Rockville, MD 20850

240-777-5118

SeamlessDocs

Read Carefully Before Completing You can complete this online form using a web browser (Firefox, Google Chrome, Microsoft Edge), cell phone, or tablet. (It will NOT work with Internet Explorer)
  1. Flu Shots will be given at our OMS FROMS clicnic to employees with confirmed appointments ONLY.
  2. To schedule an apointment at our onsite OMS FROMS clinic location, please click here. (Sign in using your County single sign-on login. Select the location "Occupational Medical Services Montgomery County Government" to see available appointments.) If you are going to an off site flu clinic or already have an appointment, skip this step.
  3. This Flu Consent and Medical Questionnaire Form should be completed within 48-hours of your scheduled appointment. Example: If your appointment is on 9/15/2022, your consent should be completed between 9/12-9/15, not before.
If you have any questions contact OMS 240-777-5118, FROMS 240-777-5185 or email OMS.Appt@montgomerycountymd.gov. Our Address is 27 Courthouse Square, Suite 180, Rockville, MD 20850. The direct entrance to our suite is on E. Jefferson Street, accross from the District Court. Use the ramp entrance. Free Parking is available at the COB Parking Garage with County ID. If you are experiencing cold or flu like symptoms (such as fever, cough, sore throat or difficulty breathing) the day of your appointment, please STAY AT HOME and contact our office to reschedule.

(Alternative format requests for people with disabilities. If you need assistance accessing this report you may submit alternative format requests by webform to the ADA Compliance Manager. The ADA Compliance Manager can also be reached at 240-777-6197 or at adacompliance@montgomerycountymd.gov. You can also fill this form out in paper at your flu shot appointment.)
Please check that you agree before continuing.
By continuing I agree that I am willing to complete a digital version of the document(s) and that information about my user session will be stored.
Signature HereClick to Sign
04/27/2024Click to Sign
Signature HereNurse Will Sign Here
04/27/2024

Create Your Signature

Please fill in your name and email and then either draw or type your signature below.

x

Signature Type

Type Draw Upload Custom
Clear Signature

Signature will be applied to the page. You will have a chance to review after signing.

Check this box to continue

x

Additional Signatures Required