Date: April 15th, 2022
Location: VTA Chaboya Division Yard, 2240 S 7th St, San Jose, CA 95112, USA
Informed Consent: Please read and sign by pressing the submit button below.
By submitting below, you are declaring under penalty of perjury under the laws of the State of California that you are the Patient or Parent/Guardian of the Patient and give LiveFreely Inc. authorization to access and view your record in the California Immunization Registry (CAIR).
Note: After clicking submit, please scroll to the top of the form to see if it has been submitted successfully.