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* Required information. |
| You must be 18 years or older to receive information |
| *Yes, I am 18 years of age or older |
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| *Patient first name: |
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| *Patient last name: |
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| Address 1: |
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| Address 2: |
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| City: |
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| State: |
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| *Zip code: |
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| *E-mail address: |
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*Date the first dose was received: |
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| Due to state restrictions, the vaccination reminders - 3 To Complete Program - cannot be used by residents of Maine. |
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I agree to permit the Merck & Co., Inc., family of companies (collectively,
"Merck") or others working on behalf of Merck to provide reminder communications
about second and third doses.
At any time, I can request a copy of the permissions I have given and ask
that personal information about me be removed from the "3 TO COMPLETE"
Reminder Program by calling 1-888-776-8364. I understand that unless I
change my permissions sooner, they will expire 1 year after Merck no
longer offers the "3 TO COMPLETE" Reminder Program.
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