Clinic Declaration | MPD Corp

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Covid-19 Health Declaration

Do you want to keep your scheduled appointment and accept the Johnson & Johnson Covid-19 Vaccine?

First Name

Last Name

Email

Yes, I want to keep my vaccine clinic appointment.

No, I want to cancel my vaccine appointment. I am under the age of 18.

No, I want to cancel my vaccine appointment. I do not want the J&J vaccine.

Date

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