COVID-19 Vaccine Registration Form
MCKINNEYCARE PHARMACY AND COMPOUNDING 4601 MEDICAL CENTER DR, MCKINNEY, TX-75069. PH:972-325-2273.
Name
*
First Name
Last Name
Birth Date
*
-
Month
-
Day
Year
Date
Gender
*
Female
Male
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
Insurance Company
Insurance ID
Back
Next
Health and Medical History
Please list down your allergies
Please check the symptoms that apply
*
Loss of taste or smell
High fever
Difficulty in breathing
Body aches
Runny nose
Diarrhea
Cough
Persistant pain or pressure on chest
Nasal congestion
Sore throat
None of the above.
Other
Have you been diagnosed with COVID-19?
*
Yes
No
If yes, please provide further details (date of diagnition, were you hospitalized or not, treatment, etc.)
ANY MASSAGE FOR THE PHARMACY
I hereby declare that all the given information is accurate and I agree to share my vaccination information with the State of Texas and CDC or where required legally. I understand that this vaccine is approved under emergency, I give my consent to the pharmacist that I will not hold him/her responsible for any reaction or after effects for the vaccine provided. I understand that vaccination is based on availability, if I don't show up at the scheduled time then I have to register again for the next available time slot.
*
Yes
Register
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