If you have difficulty using this form, please call 866-610-3885.If you have already received one dose, and would like to schedule a second dose appointment, please call 866-610-3885.
Based on your responses to the vaccine eligibility questions above, this person is not currently eligible to schedule a vaccination.
The patient is advised to attempt to schedule a vaccination again in 14 days.
The patient understands the benefits and risks of the vaccine and voluntarily assumes full responsibility for any reactions that may result. The patient understands they should remain in the vaccine administration area for 15 minutes after the vaccination to be monitored, and furthermore understands that they can review a Notice of Privacy Practice at the time of vaccination. The patient requests that the vaccine be given to them or to the person named above for whom they are authorized to make this request.