Covid-19 Vaccine Request For Age 12 and Over

Covid-19 Pfizer Vaccine Request for Age 12+

Thank you for allowing us to perform this service for you. In an effort to save you time, please have your insurance card ready.

Also, please bring your insurance card, driver's license (and passport, if applicable) at the time of your appointment.

What is the vaccine recipient's LAST NAME? *

What is the vaccine recipient's FIRST NAME? *

What is the vaccine recipient's DATE OF BIRTH? *

What is the vaccine recipient's CONTACT PHONE NUMBER? *

What is the vaccine recipient's ADDRESS OF RESIDENCE? *

Address Line 1

City

State / Province / Region

Postal Code

Country

What is the vaccine recipient's VALID EMAIL ADDRESS? *

Confirm Email

Passport Number, Issuing Country & Expiration Date *

Driver's License Number, Issuing Country/State & Expiration Date *

Do you have insurance? *

Who completed this form? *

Vaccine Recipient
Other

By signing below, I attest that all information contained herein are true and accurate.

I release Crosstown Pharmacy from any and all liabilities if I make any false or misleading statements on this form and any unfavorable resulting action(s).

I further attest that I will bring physical proof of my driver's license, passport, and any other official document (s) as proof on the day of my appointment.

By providing payment and scheduling this appointment you agreeing to the accuracy and the truthfulness of the information inputted on this document. Falsifying any information contained herein on this application is a felony crime punishable by imprisonment and/or fine. *

Agree

Signature *

**PLEASE REMEMBER TO BRING YOUR OFFICIAL DOCUMENTS WITH YOU AS PROOF**

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<img decoding="async" height="149" width="200" alt="" src="https://italpharmacy.com/wp-content/uploads/2022/11/Crosstown-Pharmacy-Logo.webp" style="font-size: 16px" class="alignnone wp-image-1071 lazyload">

Thank you for allowing us to perform this service for you. In an effort to save you time, please have your insurance card ready.

Also, please bring your insurance card, driver's license (and passport, if applicable) at the time of your appointment.

By signing below, I attest that all information contained herein are true and accurate.

I release Crosstown Pharmacy from any and all liabilities if I make any false or misleading statements on this form and any unfavorable resulting action(s).

I further attest that I will bring physical proof of my driver's license, passport, and any other official document (s) as proof on the day of my appointment.