COVID-19 Vaccine Booster Interest Form

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For the Yadkin County Medical Clinic

First and Last Name *

Email Address

Phone Number

Are you 65 years of age or older?

Yes

Other:

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Which Vaccine have you already received? *

Are you interested in a Booster dose for Pfizer, Moderna, or Janssen (Johnson & Johnson)? *

Approximately how many months ago did you complete your vaccine series? *

Submit

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