By completing the following appointment registration form, you are attesting that you are interested in receiving the COVID-19 vaccine when it is available for you.

You are also attesting that the information you are entering is accurate and verifiable by the appropriate evidence if requested.

I certify that I am: (a) at least 18 years of age; (b) the parent or legal guardian of a minor patient; or (c) the legal guardian of the minor patient. Further, I hereby give my consent to GreenClinics Laboratory, and the licensed healthcare provider administering the vaccine, as applicable (each an “applicable Provider”), to share my personal demographic in order to provide me with vaccination services for the COVID-19 vaccine. I understand that the data shared within this form will be used only and solely to determine the appointment of when the vaccine will be made available to me. I will also, if requested by representatives of GreenClinics Laboratory, and/or the healthcare professional providing my vaccination, provide proof of my eligibility for vaccination (e.g. employee badge, healthcare provider license, letter from supervisor on organization letterhead, etc.).

Disclaimer: This Platform is strictly a vaccine scheduling system developed to be used by GreenClinics Laboratory. The Platform does not give any medical advice on vaccination or any side effects. The dispensation of the vaccine is at the medical discretion of the person administering the vaccine at GreenClinics Laboratory. The Platform takes no responsibility whatsoever for any injury, medical effects or adverse effects of vaccination. It is well recognized that no vaccine is 100 percent effective. The Platform is not responsible for the rare 5-7 percent of patients who develop COVID-19 despite vaccination, or for any adverse undesirable effects or injury thereof.