Vaccine Appointment Scheduling and Consent Form
Considerations For Scheduling Your Appointment
If you require special assistance of any kind please make arrangements to bring a family member or caregiver with you to your appointment. If you do not require assistance please refrain from bringing additional people with you so we can properly social distance. Please do not arrive more than 10 minutes ahead of your scheduled appointment to avoid waiting in line. You will not be able to check-in more than 5 minutes ahead of your scheduled appointment.
EVENT INFORMATION: Perry High School
Select an appointment time
EVENT INFORMATION: Perry Jr. High
Select an appointment time
EVENT INFORMATION: Perry Upper/Lower Elementary
Select an appointment time
Vaccine Recipient Name
*
First Name
Middle Name
Last Name
Vaccine Recipient Physical Address
*
Street Address
Street Address Line 2
City
State Initials
Postal / Zip Code
Email
*
example@example.com
Date of Birth
*
/
Month
/
Day
Year
Vaccine Recipient Phone Number
*
What Vaccine Are You Requesting Today?
*
Flu
Covid 1st Dose
Covid 2nd Dose
Covid Booster
Flu/Covid
T-DAP (Tetanus, Diphtheria & Pertussis)
Prevnar 20 (Pneumonia)
Pneumovax 23 (Pneumonia)
Shingrix (Shingles)
Vitamin B-12*
*If receiving Vitamin B-12 shot, there will be a $10 charge since it is not covered by insurance
Covid Vaccine Type
Please Select
Moderna
Pfizer
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):
*
Date Signed
*
/
Month
/
Day
Year
Date
Submit Consent Form (required)
Should be Empty: