Nguyen Pharmacy COVID-19 Vaccine Registration Moderna & Pfizer

Nguyen Pharmacy COVID-19 Vaccine Appointment Scheduler

Please pick a time and fill out the information below.
Select vaccine

Other
Select Location
Appointment
Please fill out the below form.
First Name
Last Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email (must be unique to each individual)
example@example.com
By completing these fields you are attesting that you are 18+ years of age.
Please review and check the boxes below
Please review the following:

Fact Sheet - https://www.fda.gov/media/144638/download

V-Safe Registration - Get vaccinated. Get your smartphone. Get started with v-safe. (cdc.gov)
Please make sure you review the Fact Sheet and "V-Safe Registration" above.
Please agree to the following
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Nguyen Pharmacy COVID-19 Vaccine Appointment Scheduler