OLD Vaccination Order Form

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Appointments must be scheduled at least 3 business days before the vaccine clinic. Appointments may be postponed if interest is too low or high. Data from vaccine clinic records are stored for 3 years.

Email *

First Name (Patient) *

Last Name (Patient) *

Grade

Skip if NOT a student. Elementary students must be accompanied by a parent to the vaccine clinic.

Birth date *

YYYY

Pre-payment Requirement *

Check to acknowledge that you must pay by the Friday prior to the appointment date. You can pay by bank transfer to the doctor's account (Kasikorn bank, Name of account: Kriengsak Clinic, Account number: 407-2-158364). Please send the transfer's slip to the nurse's office.

I understand and accept the pre-payment requirement.

Required

Consent *

In place of a written signature, please type your full name and date. For example: John Doe 1 Sept 2019.

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