COVID Vaccine Consent Form - Kalorama Pharmacy

COVID-19 Vaccine & Boosters Appointment Form

* Please fill The required details below
Section I. Appointment Scheduler
************************************************************** Vaccine supply is limited. If you cannot keep your appointment please E-mail us to cancel the appointment. Additionally, due to vaccine requirements, we may call you to see if you can come earlier or later. If you miss your appointment, no doses will be held to guarantee your dose. **************************************************************
Please choose your Covid vaccine:*

Bivalent Pfizer (12+) BoosterBivalent Pfizer Kids (5-11yrs) BoosterPfizer Kids (5-11yrs) PrimaryPfizer Kids (3-4 yrs)Bivalent Moderna Booster (6-11yrs)Bivalent Moderna Booster (12+)Moderna (3-5 yrs)
Please pick a day and time for your Adult Covid-19 vaccine*
Section II. Personal Information
Full Name:*

First Name Ml Last Name
Phone Number:*
Current Date*

MonthDay Year
Date
Email*
* Please make sure to enter correct E-mail to receive a confirmation
Signature*

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