This registration form is to create your appointment. You must additionally fill out a consent form prior to arriving to the clinic. The consent form can be found on the confirmation page after booking your appt or on the website. You must provide copies of both your insurance card and driver's license of the insured on the day of your appointment. Please dress appropriately to receive an injection in the upper arm.

Clinic Location
First Name
Last Name
Date of Birth
Confirm Email
Mobile Phone Number
School Relationship
Student ID # (if applicable)
Services I'd like to receive
You will receive those immunizations as medically indicated by your health consultant staff. Vaccine Information Statements are available online here.

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