Appointment Request Form
Note: the information provided within is intended to aid Hometown Drug staff in providing the COVID-19 vaccine to our patients and community members in an organized (and more importantly, SAFE) fashion. **All potential recipients should fill out a separate form**
First name
*
Last name
*
Date of Birth
*
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Month
 -
Day
Year
Date Picker Icon
*
Male
Female
N/A
Phone number
*
Please use the same phone number for all patients you wish to be the primary point of contact for (i.e. children, elderly family members, etc.)
Email Address
Best time of day to reach you?
Please Select
Morning
Afternoon
Evening
Patient Availability. Select all that apply. If you are available at ANY time (no preference), please leave this section blank.
Rows
ALL DAY
11am-12pm
12-1pm
1-2pm
2-3pm
3-4pm
4-5pm
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JAN 5
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JAN 6
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JAN 7
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JAN 8
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JAN 11
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JAN 12
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JAN 13
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JAN 14
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JAN 15
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JAN 18
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JAN 19
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JAN 20
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JAN 21
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JAN 22
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JAN 25
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JAN 26
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JAN 27
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JAN 28
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JAN 29
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Additional Information For Us:
Disclosure
*
I understand this tool is intended only to allow patients to provide their availability to receive a COVID-19 vaccination from Hometown Drug.
Disclosure
*
I understand this is NOT an appointment confirmation/guarantee. **Hometown Drug staff will contact you directly to discuss a designated time frame for which you can receive your vaccine. Appointment time frames will be selected based on the information provided on this form.**
Disclosure
*
I understand ALL appointment time frames are tentative and subject to change based on vaccine and staff availability at the discretion of Hometown Drug staff. **Inability to accept a spot during an "assigned" time frame will NOT prevent you from receiving an appointment time frame or vaccination; specific time frames will be discussed when Hometown Drug staff contacts a patient to discuss the availability provided on this form.**
Disclosure
*
I understand completion of this form does NOT qualify me to receive the COVID-19 vaccine. **The qualification of each individual patient will be determined using current and up-to-date CDC guidelines and recommendations at the sole discretion of the Pharmacist-on-duty.**
Disclosure
*
I give permission to Hometown Drug and its staff to contact me to discuss the COVID-19 vaccine and potential appoint time frames
HIPAA Disclosure
*
PASTE HTD HIPAA NOTICE
Signature
Submit
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