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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 COVID-19 in the past? If so, please specify the approximate date(s).

Thank you for your interest. We will contact you once the vaccine is ready for scheduling.

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