MAKE AN APPOINTMENT AND GIVE CONSENT


Location: LiveFreely Clinic - 4820 Harwood Rd. San Jose, CA 95124

Date: Saturday November 27th, 2021

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.