Shoprite HVCC Vaccine Clinic

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone Number *

(###)

###

####

Vaccine Selection *

(This will help us ensure the right number of vaccines are available on the day of the clinic.)

COVID-19 Vaccine

Flu Vaccine

Both

Health Screening (Optional Pre-Check)

Do you currently have any COVID-19 or flu-like symptoms?

Yes

No

Have you received a flu or COVID-19 vaccine within the last 30 days?

Yes

No

Consent & Acknowledgment

Please check/select both

I understand that valid insurance is required to receive vaccination.

I consent to receive the vaccine(s) selected above and to share my insurance information for billing purposes.