Form online 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal information in the 'Patient Information' section. Fill in your last name, first name, address, mobile phone number, gender, birth date, city, state, zip code, county of residence, and email.
3. Next, provide details about your primary care provider including their name and contact information. This is essential for any follow-up regarding your immunization.
4. In the 'Insurance Information' section, indicate if you are uninsured or provide details of your insurance coverage including Medicare number and other relevant identifiers.
5. Select the vaccines you are requesting from the list provided. Ensure you check all applicable options.
6. Carefully review the precautions and indications section. Answer each question with a simple 'Yes' or 'No' as applicable to your health history.
7. Finally, read through the adverse reactions section and sign at the bottom to confirm your understanding and consent.

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