COVID VACCINE SIGNUP INFO
Please read the attached forms and check the last box
Email *
First name *
Last name *
Date of Birth *
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Address *
Phone Number *
Company Name
GENERAL PATIENT CONSENT FORM (1 of 2)
GENERAL PATIENT CONSENT FORM (2 of 2)
Do you have insurance? *
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By continuing, you have acknowledged that you have read the above form and hereby consent to treatment and/or services at enTrust Immediate Care. *
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