By submitting this request for a 1st dose COVID-19 vaccine, I
hereby certify the information provided in this request is true and that I meet
the current MDoH eligibility criteria for vaccination.
I understand that I will have to sign a separate consent form
provided by SRHS for it to administer the vaccine to me.
I will make every effort to attend my appointment and
understand that failing to do so will require me to submit a new request (a
“make-up” appointment will not be scheduled for me).
I understand that this request is for a 1st dose COVID-19
vaccine only. I understand that I do NOT
need to request a 2nd dose COVID-19 vaccine appointment as the 2nd dose will be
scheduled for me at the time I receive my 1st dose of the vaccine.