Sugar Land Vaccine Form | DeliverIt Pharmacy

Covid-19 Vaccine Inquiry Form

First Name

Occupation

Last Name

Phone Number

Date of Birth

My body temperature is lower than 98.6°F/ 37.5°C

I am not experiencing the symptoms: fever, cough, sore throat

I haven’t been in close contact with a Covid-19 patient in the last 14 days

Upload Driver's License/ID Card

Upload supported file (JPG, PNG)

Upload Insurance

Upload supported file (JPG, PNG)

Initials

Date

I declare that the info I’ve provided is accurate & complete

Please list any health conditions, allergies, etc.

Thanks for submitting! Our pharmacists are working hard to get through our inquiry forms, so please do not call the pharmacy and check your e-mail for a confirmation e-mail!

(Please also make sure to check your junk/spam email if you do not see an email in your inbox.)

This form no longer accepts submissions.

Covid-19 Vaccine Inquiry Form

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