Pfizer COVID Vaccine

Pre-registration for individuals 12 years and older

First Name

Date of Birth

Email Address

Last Name

Phone

Gender

Street Address

City

State

Zip code

Primary Insurance Name:

Primary Insurance ID#

Primary Insurance Group #

Primary Insurance Phone Number (on back of card)

Subscriber Name

Subscribers DOB

Initials

Today's Date

By checking the box below, you certify that you have read the entire list of eligible priority groups, and you certify under penalty of law that you are eligible for the COVID-19 Vaccination. You further acknowledge that you are placing the legal equivalent of your handwritten signature on such certification.

Review the CDC Prevaccination Checklist

Thank you for submitting your request. Someone from our office will contact you to schedule your appointment.

If you have any questions or concerns, please contact our office.

Pfizer COVID Vaccine

Pre-registration for individuals 12 years and older

For Life-Threatening Emergencies Call 911