English Road Pediatrics - COVID Vaccine Clinic
CLINIC DAYS:

First Dose: Wednesday, May 12 2:00-7:00pm
2nd Dose: Wednesday, June 2 2:00--7:00pm

First Dose: Friday, May 14, 1:00-4:00pm
Second Dose: Friday, June 4, 1:00-4:00pm

Pfzier
MUST BE ABLE TO RECEIVE SECOND SHOT IN ORDER TO GET FIRST
1800 English Road, Rochester, NY, 14616
585-225-2525
englishroadpediatrics.com
(responses are deleted upon entering into our system)
Are you a patient at English Road Pediatrics? *
Are you a parent of a patient at English Road Pediatrics? If yes, please list your child's name: *
Required
Patient Information
Full Name *
Address (please include zip code) *
Phone Number (xxx-xxx-xxxx) *
Date of Birth *
MM
/
DD
/
YYYY
Gender *
I am: *
Required
Insurance Information
We accept most insurances EXCEPT Medicare.
Insurance Type (ex. Fidelis, Excellus, etc.) *
Insurance Subscriber Name: *
Subscriber Date of Birth *
MM
/
DD
/
YYYY
Relationship to Subscriber *
Insurance ID Number: *
Thank you for your submission
If you qualify based on current NYS guidelines, we will book a slot and call you to notify of your appointment time.
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy