• COVID-19 Immunization Questionnaire

  • Please read the information sheet (below) from the CDC for the Pfizer COVID-19 vaccine, then complete the following questionnaire and consent form.  Please ask all questions you may have.  

    Please Note:  If you are receiving your first dose today, please contact us in 3 weeks to schedule your booster dose.  If you are receiving your second dose, please contact us in 8 weeks to schedule your final dose.  Thanks very much!

    ***Children receiving vaccines should remain in the vehicle with their seat belts fastened***


  • Consent for Immunization

  • I have been given a copy and have read, or have had explained to me, the information provided by the Centers for Disease Control (CDC) for the COVID-19 vaccine I/my child am to receive today.

    I have had a chance to ask questions and they have been addressed to me satisfaction.

    I understand the benefits and risks of the COVID-19 vaccine to be given.

    I give my consent for the COVID-19 vaccine to be given to me/my child at this time.

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