• COVID-19 Vaccine Consent Form

    In order to receive the vaccine, you must be in the most appropriate phase of the vaccine rollout. Visit this link (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations.html) for more information at the federal level. States may have a different approach.
  • Attention:

    Please DO NOT proceed in filling out this form unless you have already been contacted by Niagara Apothecary to schedule your vaccination. *Speaking to Niagara Apothecary and being put on our waiting list does not qualify you as scheduled for a vaccination, please do not fill this form out prematurely. Any form received without prior approval/appointment by Niagara Apothecary will be discarded.
  •  /  /
    Pick a Date
  •  
  •  /  /
    Pick a Date
  •  
  •  
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancel of
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancel of
  •  
  • Clear
  •  /  /
    Pick a Date
  • Should be Empty: