10/24/2021 新冠疫苗接种预约表格  Vaccination Scheduling Form (Pfizer Vaccine)
这个表格用来注册下面新冠疫苗接种活动:
日期：2021年 10月24日，星期日上午 10 点至下午4 点
地点: 6401 Castor Avenue, Philadelphia, PA19149
*这个活动可以打 第一剂、第二剂或 第三剂 (额外/加强剂量) 的 瑞辉和摩登纳COVID-19 新冠疫苗 。
(10/18/21 update)
-----------------------------------------------------------
This form allow sign up for Pfizer COVID19 vaccination:
Date： Sunday 10/24/2021; 10 AM - 4 PM
Location: 6401 Castor Avenue, Philadelphia, PA19149
This COVID-19 vaccination event can provide Pfizer and Moderna First, Second, or Extra/Booster Dose of the COVID-19 Vaccine.
Sign in to Google to save your progress. Learn more
英文名和姓 First - Last Name *
电子邮箱 Email *
如果没有电子邮箱， 输入 ’0‘， enter '0' if no email
电话号码 Phone # *
方便接电话时间  Best time to contact you
地址 Address
您地址的邮区号码 Enter Zip code of your address
邮区号码 Zip code *
您地址的邮区号码 Enter Zip code of your address
性别 Gender *
年龄组 Age range *
生日 Birthday (月，日，年） *
MM
/
DD
/
YYYY
谁应该接受加强剂量？ (第三针）
如果您是註冊打額外劑量或增強劑量，請檢查以下內容並確定您符合條件。下載至原文 https://covid19.chineseinus.org/covid-vaccine-booster-doses-are-now-approved/； 9/29/2021  .  摩登纳加强針跟瑞辉加强针是一样的标准。
Captionless Image
Who should get a booster dose?
If you are registered for an extra dose or a booster dose, please read  the following and make sure you are eligible. Moderna booster dose has the same requirements like Pfizer booster dose.
Captionless Image
健康类别 Health Category *
如果您要打加强剂量 (第三剂），请告知你是属于以下哪一种健康情况。“完全接种” 指已经打了头俩剂辉瑞疫苗。 If you want the third dose, which of the following categories do you fall under?  "Fully vaccinated" meant had completed the first 2 Pfizer doses.
需要的疫苗 Want Vaccine   *
你要注册打哪种新冠疫苗 (每人填一份表）？ Which COVID19 Vaccine do you sign-up for?  (one record per person)
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms