Covid-19 Vaccination Clinic

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Last Name*

Date of Birth*

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Email Address*

Street Address*

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Ethnicity*

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Insurance Type*

Insurance is not required to receive the vaccine, however if you have insurance, it is collected for billing purposes. There is no out of pocket cost to you for the vaccine regardless if you have insurance or not.

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Name of Insurance Carrier*

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COVID-19 Vaccine Dose Requested*

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Chronic Health Conditions*

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