COVID-19 Vaccine 1A Distribution Healthcare Provider Screening
This form is for healthcare providers ONLY who are looking to receive the COVID-19 vaccine. If you are not a healthcare provider please check back at a later date. Once this form is submitted, a member of our team will review the request. You will receive an email link to schedule your vaccine from COVID@hartzells.com once eligibility is confirmed AND vaccine is available. Please do not call the pharmacy to follow up on requests. We will only schedule appointments for the number of doses we receive from the Department of Health. Requests will be processed in the order received.
At this time COVID19 vaccine distribution is limited to healthcare providers and those living in a qualified long term care setting. What is your place of employment?
*
What is your position?
*
Please upload proof that you are a healthcare worker. Eligible documents include, employee ID badge, professional license, pay stub or W2, or other proof of employment by a health care entity.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Name
*
First Name
Last Name
Birthdate
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Should be Empty: