Covid-19 Vaccine or Booster Appointment

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Please carefully answer these questions, which were designed for patient safety. These questions will be asked again before vaccination. We may not be able to administer the vaccine if the answers are different.

First and Last Name of Person being Vaccinated *

Date of Birth *

YYYY

Gender *

Age in Years *

Street Address *

City *

State *

Zip Code *

Mobile Phone *

Email ID *

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