Appointment

MAKE AN APPOINTMENT AND GIVE CONSENT

Date of Birth

Gender assigned at birth:

Male

Female

Do you have medical insurance? (You do not need need insurance to recieve a vaccine)

Yes

No - I attest that I do not have any medical or pharmacy insurance

If you have medical insurance:

Please choose which vaccine you received as your 1st dose:

Date of 1st dose:

Please Choose which vaccine you received as your 2nd dose:

Date of 2nd dose

Please choose your preferred booster vaccine:

Informed Consent: Please read and sign by pressing the submit button below.

By submitting below, you are declaring under penalty of perjury under the laws of the State of California that you are the Patient or Parent/Guardian of the Patient and give LiveFreely Inc. authorization to access and view your record in the California Immunization Registry (CAIR).

Today's Date

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