Cancellation Form

1
Name
First Name
Last Name
2
Please enter your Date of Birth
3
Phone Number
Area Code
Phone Number
4
Email
example@example.com
5
Which type of appt were you scheduled for?
Covid Dose 1 or 2
Other (Flu, Shingles, Tetanus, etc...)
COVID BOOSTER
COVID TESTING APPT
6
Please Enter the date of your appointment you are cancelling
Date
Year
Month
Day
7
Please add any comments that could help our team.EX: I signed up twice, please cancel this appt, or I live off-island and didn't realize I had to take a ferry to get to the site....
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Ok
Ok
8
By signing below I understand that I am cancelling my appointment. I understand that this process cannot be undone. If this is a dose 1 appointment that is being cancelled I understand that both my dose 1 and dose 2 appointments will be cancelled.
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Should be Empty: