COVID-19 Vaccine Appointment Form: **Pfizer ONLY, age 16 and older**
**IF SECOND SHOT, ONLY MAKE APPOINTMENT IF YOUR FIRST DOSE WAS PFIZER**
Please enter a valid phone number.
Street Address Line 2
State / Province
Postal / Zip Code
Date of Birth
What is your gender assigned to birth?
What is your ethnicity?
American Indian or Alaskan Native
Asian or Pacific Islander
Black or African American
Hispanic or Latino
Do you have any allergies to medications, insects, food, or vaccine components?
Yes (what are you allergic to and what was your reaction?)
Do you have insurance? (If yes, please upload a picture of front and back of insurance card below. If no, please upload a picture of your driver's license.)
Please upload image of your insurance card or driver's license here.
Drag and drop files here
Choose a file
Please print and complete this consent and screening form prior to appointment.
Select which dose you plan on receiving: (If 2nd dose, please bring your CDC Vaccination Record Card **PFIZER ONLY**)
**These are appointments for Pfizer only!**
IF UNDER 18, MUST BE ACCOMPANIED BY A PARENT OR GUARDIAN.
Should be Empty: