Vaccine Clinic
Thurs. October 10th in the UJC Gym
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Birth Date
*
-
Month
-
Day
Year
Date
Please bring your insurance card and ID with you.
If you have any questions, please email mvogel@ujcvp.org or call 757-930-1422
Shot Preference
*
Flu Shot - regular/senior dose (for ages 3+)
Covid Booster (for ages 18+)
Both
Please Select Appointment Time Slot
*
Submit
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