COVID-19 Vaccine Appointment Form: **Pfizer ONLY, age 16 and older**
**IF SECOND SHOT, ONLY MAKE APPOINTMENT IF YOUR FIRST DOSE WAS PFIZER**
Appointment
*
Name
*
First Name
Middle Initial
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Questionnaire
Date of Birth
*
/
Month
/
Day
Year
Date
What is your gender assigned to birth?
*
Please Select
Female
Male
Intersex
What is your ethnicity?
*
Please Select
American Indian or Alaskan Native
Asian or Pacific Islander
Black or African American
Hispanic or Latino
White
Other
Do you have any allergies to medications, insects, food, or vaccine components?
*
No
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.)
*
Yes
No
Please upload image of your insurance card or driver's license here.
Browse Files
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Choose a file
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of
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**)
*
1st dose
2nd dose
**These are appointments for Pfizer only!**
IF UNDER 18, MUST BE ACCOMPANIED BY A PARENT OR GUARDIAN.
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