Flu/Covid Vaccine Clinic
Monday October 27
3:30-6pm
3205 Catalpa Dr, Berkley, MI 48072
How many patients are registering?
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1
2
3
4
5
6
Patient 1 Information
*
Full Name
Date of Birth
Patient 1 Vaccine
Flu
Covid
Patient 2 Information
Legal Full Name
Date of Birth
Patient 2 Vaccine
Flu
Covid
Patient 3 Information
First
Date of Birth
Patient 3 Vaccine
Flu
Covid
Patient 4 Information
Legal Full Name
Date of Birth
Patient 4 Vaccine
Flu
Covid
Patient 5 Information
Legal Full Name
Date of Birth
Patient 5 Vaccine
Flu
Covid
Patient 6 Information
Legal Full Name
Date of Birth
Patient 6 Vaccine
Flu
Covid
Home Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Name
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First Name
Last Name
Parent/Guardian Phone Number
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Format: (000) 000-0000.
Parent/Guardian E-mail
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example@example.com
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Primary Insurance Type
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BCBS/BCN
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Other/Uninsured/Self-Pay
Insurance Policy Information
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Subscriber/Member ID #
Group Number
Insurance Subscriber Name & Date of Birth
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Full Name
Date of Birth
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Appointment
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