QR Code Vaccination Card Order Form

Complete the registration form to order your QR Code Vaccination Card.

Please note:
Registration forms sent before 4 PM can be picked up on the same date.
Registration forms sent after 4 PM can be picked up on the next business date.

Please provide the following information:

First Name *This question is required.

Last Name *This question is required.

PuntoMio/ EuroMio Account Number (if you're a member)

E-mail Address *This question is required. This question requires a valid email address.

Phone Number *This question is required.

Please upload a photo of yourself. This will be used as a profile picture for your QR Code Vaccination Card (optional).To upload a photo of yourself click 'Browse'. A system window opens and prompts you to select the file. Find the file and click 'Open'. Then, click 'Upload'.

File: {{filename}} delete

Please upload your QR Code Vaccination Certificate *This question is required.To upload a copy of your valid ID click 'Browse'. A system window opens and prompts you to select the file. Find the file and click 'Open'. Then, click 'Upload'.

File: {{filename}} delete

Please upload a copy of your valid ID *This question is required.To upload a copy of your valid ID click 'Browse'. A system window opens and prompts you to select the file. Find the file and click 'Open'. Then, click 'Upload'.

File: {{filename}} delete

Where would you like to pick up your QR Code Vaccination Card? *This question is required.