COVID vaccine interest form for families wishing to receive the COVID vaccine
Child's Name
*
First Name
Last Name
Child's Date of Birth
*
Best Number to call when an appt becomes available
*
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Area Code
Phone Number
Name of Person to call
First Name
Last Name
Please read the following options and choose one.
*
My Child is between the ages of 6 months to 11 years.
My Child is 12 years of age or older
Please Read All Options and Choose all that Apply
*
I am a patient of All Star Pediatrics.
I need to schedule my child's initial doses of COVID vaccine
My child has completed their initial series and is in need of a booster dose at this time.
I am aware my COVID consent form will come 72 hours ahead of my appt via a text or email from Phreesia and I need to fill out my pre-registration as soon as possible after I receive it.
Submit
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