Appointment Ut

Friday, January **, ****

Jan **: Essential Personnel and Age 70+

COVID-19 Vaccine Appointment Form

PDF Password Vaccine2021!

Name Gloria Geese

Address **** ********* ***

Ogden, UT, 84414

Date of Birth - Fecha de Nacimiento March 20 1947

Race White

Ethnicity Not Hispanic or Latino

Phone Number 801-***-****

E-mail Address ******.*****@*.***

Which priority population are you a

part of?

70 years of age or older

COVID-19 Vaccination Appointment -

Jan 27

Wednesday, Jan 27, 2021 12:15 - 12:30

Location Dee Events Center

We will be providing Moderna AND P zer-BioNTech vaccines.

**You are required to review the Moderna Vaccine Fact Sheet and the P zer-BioNTech Fact Sheet. Moderna vaccine is not authorized for individuals 17 and under. P zer-BioNTech vaccine is not authorized for individuals 15 and under.** By checking the box below you a rm

all the information provided above is

correct.

Yes

Contact this candidate