UPMC Student Vaccination Clinic Request
Please complete this form if you would like to receive the Pfizer vaccine at the Hopewell High School on May 26 from 2:30-5:30. The second shot would take place on June 17 or 18 (date TBD). UPMC will be hosting this clinic.
1. Which School do you attend? *
First Name *
Middle Name *
Last Name *
Date of Birth *
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Gender *
Street Address *
City *
State *
Zip Code *
Email Address *
Cell Phone Number *
Do you have a history of anaphylaxis with vaccines-that is a severe allergy requiring rescue medication to other vaccines or injectable therapies? (note: this does not include a history of allergies, including food, environmental, or oral medications)? *
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