Vax & Backpacks Pre-Registration Form

Vax & Backpacks Pre-Registration Form
If you would like to schedule a school physical or immunizations for your child during the event, be prepared to upload the following document:

• Patient Intake Form
Parent's Information
Parent/Guardian's Name*

First NameLast Name
Parent's Email Address
example@example.com
Parent's Phone Number*
Please enter a valid phone number.
How many children are you registering for this event?*
Children's Information
Child #1 Name*

First NameLast Name
Child #1 Date of Birth*

MonthDayYear
Date
Child #2 Name*

First NameLast Name
Child #2 Date of Birth*

MonthDayYear
Date
Child #3 Name*

First NameLast Name
Child #3 Date of Birth*

MonthDayYear
Date
Child #4 Name*

First NameLast Name
Child #4 Date of Birth*

MonthDayYear
Date
Would you like to schedule an appointment for your child/children's school physical and/or immunizations?*

Yes, physical onlyYes, immunizations onlyYes, both physical and immunizationsNo appointment needed

Use the calendar to book an appointment for child physicals or immunizations with Valerie Croney, APRN OR Ifeoma Nwofor, APRN. Appointment slots are 1 hour long and you can book for up to 2 children per slot.
Book Appointment with Valerie Croney, APRN*
Book Appointment with Ifeoma Nwofor, APRN*
Click here to download and fill out the patient intake form: Intake Form. Once complete, upload the form below. Your appointment will not be confirmed without this form. If you have more than one child in need of an appointment, make sure to upload an intake form for each child.
File Upload*

Cancelof

Parent's Information