Bay clinic COVID VACCINATION Event Scheduler
Please fill out the following information. Once completed, you will receive an EMAIL confirmation. Mahalo!
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Email *
FIRST Name *
LAST Name *
Gender *
Date of Birth *
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Age as of today *
Phone Number (000-000-0000) *
Home Address: (Street, City, State, Zip Code) *
Which clinic day will you be attending? *
Choose the vaccination you would like to receive. *
If you are scheduling an additional dose or booster dose, please indicate the date you received your 2nd dose (Moderna and Pfizer) or 1st dose for Johnson & Johnson.
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If the patient is a minor, please provide the following information: Parent or Guardian's name, Date of Birth, and Relationship to the patient.
Please select all race(s) that apply to you: *
Required
Please select your ethnicity: *
Please let us know your preferred scheduled time. *
Additional Comments
A copy of your responses will be emailed to the address you provided.
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