Liberty Pediatrics - COVID Vaccine Pre-Registration Form
Liberty Pediatrics is approved as COVID vaccine distribution clinic for adults. At this time, we will not be offering the vaccine to anyone under 18. We will get the vaccines in middle of January. Please fill out the form completely to secure your slot. We will give you a call when you qualify to get vaccine and schedule you in.
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Email *
First Name *
Last Name *
Date of Birth *
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Phone Number *
Sex *
Have you ever been diagnosed with COVID-19? *
Have you ever been diagnosed with Diabetes? *
Have you ever been diagnosed with High Blood Pressure? *
Have you had allergic reaction to any vaccine in the past? *
When was your last annual check up? Please enter today's date if you have not had any check up in last 2 years. *
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Who is your Primary Care Physician *
A copy of your responses will be emailed to the address you provided.
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