Here is a friendly reminder email of your appointment

Appointment

{pleaseSelect:date}

Duration

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Timezone

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Add to Google • Outlook • iCal

Reschedule or Cancel Appointment

{form_title}

Name	{name}
Social Security Number	{socialSecurity}
Date of Birth	{dateOf}
Gender	{gender}
Phone Number	{phoneNumber}
Email	{email4}
Retype Email	{retypeEmail29}
Address	{address}
Insurance Company	{insuranceCompany10}
Insurance ID Number	{insuranceId11}
Policy Holder First Name	{policyHolder}
Policy Holder Last Name	{policyHolder35}
Policy Holder Date of Birth	{policyHolder37}
Policy Holder Relationship to Client	{policyHolder78}
Upload the FRONT of your insurance card (e.g. red, white & blue Medicare card)	{uploadThe39}
Upload the BACK of your insurance card	{uploadThe}
Is this your first, second or third COVID-19 vaccination?	{isThis}
Do you have any of the following chronic health conditions?	{doYou}
Have you had a severe allergic reaction (e.g., anaphylaxis) to a COVID-19 vaccine, a component of the COVID-19 vaccine (including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures) or Polysorbate?	{haveYou}
Have you had a severe allergic reaction (e.g. anaphylaxis) to another vaccine (not including Pfizer-BioNTech vaccine) or any other injectable medication?	{haveYou83}
Do you have a bleeding disorder or are you taking a blood thinner?	{doYou84}
Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?	{doYou85}
Do you have a fever?	{doYou87}
Are you feeling sick?	{areYou}
Are you pregnant?	{areYou89}
Are you breastfeeding (nursing)?	{areYou90}
Have you received another vaccine in the last 14 days?	{haveYou91}
Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication? This would include food, pet, environmental, or oral medication allergies	{haveYou92}
Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?	{haveYou93}
Have you had a positive test for COVID-19 in the past 10 days?	{haveYou94}
I attest that the above information is true and correct to the best of my knowledge. I hereby give my consent to the licensed healthcare provider administering the vaccine, as applicable, to share my personal, demographic and health condition information in order to provide me with vaccination services for the COVID-19 vaccine	{iAttest}
Signature	{signature}
	{input26}
Please select a time for your appointment	{pleaseSelect}
Terms and Conditions	{typeA}
	{typeA104}
ProgressBar	{typeA105}
	{typeA106}
	{typeA108}
Lob Address Verification	{typeA111}

Vaccine Clinic Registration Form

Influenza Vaccine Information Statement

Health and Medical History