**Please keep your appointment or call if you need to cancel or change it. If you miss an appointment, no doses will be held to guarantee your dose.**
Section I. Personal Information
Section II. Questionnaire for Immunization
Section IV. Signatures
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA), a copy of which I was provided with this Consent and Release. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent and Release.
Please enter your insurance information:Insurance Information Member ID Group Name Policy Holder & Policy Holder Birthdate
By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.