Vaccine Registration – LifeCare Medical Center

LifeCare Public Health will be offering a Covid Vaccine Clinic for those 12 years of age and older on Wednesday, June 9^th from 2 to 6 pm. This Pfizer, Drive-thru clinic will be held at LifeCare Public Health and is focusing on high school and college students, however anyone that is not vaccinated is welcome. Please register below if interested.

This is a two dose vaccine. You will automatically have your second dose appointment scheduled for June 30th when you are given your first dose appointment.

Please strive to keep your 2^nd dose appointment with the same provider.

If you will not be in attendance with your child, please complete the consent form and have them bring this with to the vaccine clinic.

Full Legal Name (person being immunized)*
First Middle Last
Parent or Guardian (if under age 18)*
First Middle Last
Date of Birth (person being immunized)*
MM slash DD slash YYYY
Email
Phone Number*
Please provide the number that is best to reach you.
Existing Health Conditions

If applicable, please list all.
Are you currently in quarantine due to being exposed to someone with Covid 19?
- Yes
- No
Are you currently ill with COVID 19 and in your isolation period?
- Yes
- No

Coronavirus Disease (COVID-19)