Maimonides COVID-19 Vaccine Appointment Standby List

COVID-19 Vaccine Appointment Standby
Please complete this form ONLY if you are able to arrive at Maimonides Medical Center (4802 10th Avenue, Brooklyn, NY 11219) within one hour of text notification. Completing this form does not guarantee you a vaccine appointment.
Name*
First NameMiddle NameLast NameSuffix
Mobile Phone Number*
Please enter a valid phone number.
Date of Birth*
MonthDayYear
Date
Email Address*

Confirmation Emailexample@example.com
Zip Code*
Vaccine Eligibility Attestation

I understand that only health care workers, workers in other specified occupations, individuals aged 65 years and older, and residents of specified facilities, as defined by the New York State Department of Health, are currently eligible for COVID-19 vaccination. I understand that only individuals who live or work in New York State are currently eligible. I attest that I am eligible to receive the COVID-19 vaccine based on the current New York State Vaccination Program Guidance which can be found here.
Signature*
Clear
I understand that completing this form does not guarantee registration for a COVID-19 vaccine appointment at Maimonides Medical Center. I confirm that I am able to arrive at Maimonides Medical Center within one hour of text notification. I consent to receive text messages from Maimonides Medical Center.*
I agree
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