By completing this form, you certify that you are at least 12 years of age and live, work or study in New York State.

If you are under 18, you must have consent from your parent or legal guardian. This consent can be in-person, written, or by phone at the time of the appointment.

The COVID-19 vaccine is free of charge for everyone, whether or not you have insurance. Although your insurance information is requested, please be assured that you will NOT be charged for the vaccine.

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