Covid and Flu Vaccine Study
Please answer the below questions and then continue to the calendar to schedule an appointment with us!
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Age
*
1. Kindly document the following information:
*
2. Have you received a Covid Vaccine or tested positive for covid in the last 3 months?
*
Yes
No
3. Have you received a flu vaccine in the previous season (since Sep 2023)?
*
Yes
No
4. Have you received a flu vaccine or tested positive for the flu in the last 5 months?
*
Yes
No
5. Have you received a flu and or COVID19 investigational vaccine in the last year as part of a clinical trial?*
*
Yes
No
6. Have you received any other vaccines in the last 28 days?
*
Yes
No
7. Have you ever had an anaphylaxis or severe hypersensitivity reaction with any vaccine?
*
Yes
No
8. We provide an option to set up transportation services with us for pick up and drop off to your scheduled appointments. Would you require transportation for this visit?
*
Yes
No
MDC- 710 Lawrence Street, Tomball, TX 77375
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