Pfizer:_____ Moderna:_____ Pfizer (5-11):_____
CVMS: _____
1st Dose Scheduled: ______ Closed ______
2nd Dose Scheduled: _____ Closed ______
3rd Dose scheduled ______Closed______
4th Dose scheduled ______Closed______
billed in PC_____manual bill______no ins____
ask for ins cards YES/NO______________