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Vaccine Scheduling
Step 1
Choose Vaccines
Choose up to three vaccinations:
Vaccine Scheduling - Step 1 of 5 - Choose Vaccines.
Certain vaccines may not be available due to age restrictions or other factors.
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All Vaccines
Everyone 18+ years
19-26 years
50+ years
65+ years
Pregnant Women
Patients with Diabetes
Healthcare Workers
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Weakened Immune System
All Vaccines
You can choose up to 3 vaccines.
Continue to Scheduling
Step 2
Schedule
Step 3
Patient Details
Legal First Name
Middle Initial
Legal Last Name
Address
Apt, Suite, Etc. (Optional)
City
State
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ZIP Code
Date of Birth
MM
/
DD
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YYYY
Sex Assigned at Birth
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Male
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Weight
lb
Race
American Indian or Alaska Native
Asian
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Hispanic or Latino
Native Hawaiian or Other Pacific Islander
Other Race
White
Not Specified
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Not Specified
Contact Information
We will use this info to contact you about your appointment.
Phone Number
(xxx) xxx-xxxx
Email Address
Provider Information (Optional)
Primary Healthcare Provider
Provider Address
Apt, Suite, Etc.
City
State
Select State...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP Code
Provider Phone
(xxx) xxx-xxxx
Provider Fax
(xxx) xxx-xxxx
Insurance Information (Optional)
Are you covered by commercial or federally funded healthcare insurance?
Yes
No
Continue
Step 4
Medical Information
Please answer the following questions to help us make sure the vaccine is right for you:
Continue
Step 5
Vaccine Consent
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I accept the consent
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I have read and agree to the
Terms of use
and
Notice of Privacy Practices.
Patient's Legal Name
Date
05/16/2022
Full Name of Legal Guardian or Power of Attorney (If Applicable)
Relationship (If Applicable)
Ex. Mother
Submit to confirm your appointments.
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