Wallet With Free Gift Card

Tell Us About Your Health

Your answers will help us identify any contraindications, or precautions to take, prior to your vaccine. Please mark YES or NO for each question.

WhereChange

Southgate Shopping Center

2515 S. Florida Ave., Lakeland, FL 33803

When

Patient InfoEdit

Chris Smith - Feb. 20, 1970

123 Easy Street, Lakeland FL

Test

Test

Publix PharmacyChange

Southgate shopping Center

2515 S. Florida Ave., Lakeland, FL 33803

Your HealthEdit

Consent

By checking this box, I certify that I am the patient or the patient's guardian/personal representative signing on behalf of the patient, and that I have read, understood, and agreed to all the statements above.