KIDS (5-11 Years) Pfizer BioNTech COVID-19 Vaccine Appointment
Vaccine you're scheduling for: KIDS (5-11 Years) Pfizer BioNTech COVID-19.
Please choose age eligibility
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Please Select
5-11 Years old
Are you scheduling for 1st or 2nd dose
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Please Select
1st dose
2nd dose
Vaccine Recipient Name
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First Name
Middle Name
Last Name
Select an appointment time:
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Vaccine Recipient Physical Address "No PO Box"
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Street Address
Street Address Line 2
City
State Initials
Postal / Zip Code
Date of Birth
*
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Month
/
Day
Year
Gender at birth
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Male
Female
Race
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American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Ethnicity
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Hispanic or Latino
Not Hispanic or Latino
Unknown
Drug/Food Allergies (If no allergies "type none" )
blanks
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Cell Phone
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Please enter a valid phone number.
Email
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example@example.com
Do you have health Insurance?
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YES
NO
Social Security Number (Optional)
No dashes
Name of Parent/Guardian to accompany child to appointment.
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