Cedar Care Village Pharmacy Flu Vaccine Form 2021
To speed the process of flu vaccine registration while adhering to CDC-recommended social distancing policies, please complete this form to pre-register for a vaccine. You must receive your vaccine within 24 hours of submitting this form. Contact the pharmacy at 937-766-2273 if you have any questions.
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What day would you like to receive the vaccine?
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Full Name
Preferred Phone Number (with area code)
Can Cedar Care send you a text when your vaccine is ready?
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Please provide the name of your primary physician and office phone number or fax.
Date of Birth
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Gender
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Are you currently pregnant, breastfeeding, or planning to become pregnant in the next month?
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