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?
Preferred Phone Number (with area code)
Can Cedar Care send you a text when your vaccine is ready?
Please provide the name of your primary physician and office phone number or fax.
Date of Birth
Are you currently pregnant, breastfeeding, or planning to become pregnant in the next month?
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This form was created inside of Cedar Care Village Pharmacy.