Appointment

MAKE AN APPOINTMENT AND GIVE CONSENT

Date of Birth

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

Date: April 15th, 2022

Location: VTA Chaboya Division Yard, 2240 S 7th St, San Jose, CA 95112, USA

Please choose a time slot:

10:00 a.m. - 10:30 a.m.

10:30 a.m. - 11:00 a.m.

11:30: a.m. - Noon

Noon - 12:30 p.m.

12:30 p.m. - 1:00 p.m.

1:00 p.m. - 1:30 p.m.

1:30 p.m. - 2:00 p.m.

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