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Available Forms

Pfizer COVID Vaccine Request

Pfizer COVID-19 Vaccine Request for Patients ages 12+

 
Does the patient have any allergies to medications? Please select Yes or No.
 
If the patient has any other allergies, please describe the allergy (such as pollen, pet, latex, etc.) and severity of reaction.
 
Has the patient had any doses of COVID vaccine? If so, please specify the approximate date(s) and which vaccine.
 
 

Thank you for your request. We will contact you within 1 business day.

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