CANCELLATION of Immunization Appointment
If you've booked an appointment with us and would like to cancel, please fill out the form below!
What type of appointment are you cancelling?
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COVID-19 Vaccine
Flu Shot
Both Flu and COVID
Other
Enter Appointment Date and Time that you would like to cancel: (Date and Time / ex. November 9th 2021 @ 10AM)
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Patient Name:
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First Name
Last Name
Patient Date of Birth:
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-
Month
-
Day
Year
Date
Email Address for Cancellation of Confirmation
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example@example.com
I understand and attest to the fact that I am requesting to cancel a pre-existing appointment for vaccination. I also agree that if I would like to receive another vaccine, then I must sign-up for an appointment via the website, even if my preferred appointment time is no longer available.
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I agree and understand
Date of Form Completion
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Month
-
Day
Year
Date
Signature of patient or authorized person for consent
*
Submit
Should be Empty: