2026 PSD Back to School Immunization Clinic
Gig Harbor Primary Care- 4423 Pt Fosdick Dr NW Suite 200
This event is being held for PSD students between the ages of 5-18. If possible, please bring current vaccine record. Vaccine records can be found at myirmobile.com.
Name of person receiving vaccine
*
First Name
Last Name
Birth Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Gender
*
Female
Male
Unspecified
Name of Parent or Legal Guardian if person receiving immunization is under 18 years of age.
First Name
Last Name
Race
*
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Black or African American
Latino
White
Unknown
Other
Ethnicity
*
Non Hispanic
Unknown
Hispanic
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Indicate the Date You Plan on Attending
08/19/2026 1pm- 4:30
09/02/2026 1pm- 4:30
Insurance Company- if applicable
Insurance ID- if applicable
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Health and Medical History
Does the person to be vaccinated have an allergy to an ingredient in this vaccine?
*
Yes
No
Has the person to be vaccinated ever had a serious reaction to a vaccine in the past?
*
Yes
No
Has the person to be vaccinated ever had Guillain-Barré syndrome?
*
Yes
No
Select which immunization you require.
*
DTap/ Tdap
Hepatitis B
MMR
Polio
Varicella
Signature of person receiving Immunization. If under 18, parent / legal guardian must sign below. By signing you confirm that all information entered in this form is accurate. I understand that Gig Harbor Primary Care may use my Name, Date of Birth, Medical Conditions and Allergy information in this form to help schedule, administer and treat me in the event of a medical emergency. The use of this information will be limited to only individuals directly working at the vaccination site or within Gig Harbor Primary Care as it relates to my care. This form information will not be shared in any way or form without my consent in the future. The record of this vaccination will be sent to Local and State authorities as required.
*
Register
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