DOMINICAN VACCINE CLINIC
PATIENT INFORMATION
(Please print clearly)
Name
*
First Name
Last Name
MI
D.O.B.
*
/
Month
/
Day
Year
Date
Have you used New City Pharmacy?
Yes
No
Home Address
City
*
State
Email
example@example.com
Phone Number
Please enter a valid phone number.
Which vaccine(s) would the patient like to receive today?
*
Influenza HD (65+)
Zoster (Shingles)(50+)
P neumonia (65+)
RSV (60+)
Influenza (18+)
Tdap
MMR
COVID-19 (18+)
Which Covid Vaccine would you prefer? If you have no preference you will receive the vaccine with the greatest on hand quantity. If there is an availability issue you will receive a text.
Pfizer
Moderna
No preference
Vaccine Appointment
*
Submit
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