COVID-19 Vaccine Interest Form

COVID-19 Vaccine Interest Form
COVID-19 vaccines will be coming to our pharmacy soon! Please complete the information below, and we will contact you as it becomes available. Please note, completing this form does not guarantee a vaccine. We look forward to serving you!
Patient Name
First NameLast Name
Birth Date
MonthDayYear
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Please select which of the following apply to you. If more than one apply
I work in a healthcare setting (i.e. hospital, long-term care facility, emergency medical services, home health care, outpatient clinic, pharmacy, public health, mortuary services, school nurse)I am a resident of a long-term care facilityI am 65 years of age or olderI have at least one chronic medical condition that puts me at a higher risk for COVID-19 (i.e. cancer, chronic kidney disease, COPD, heart conditions, organ transplant, obesity, pregnancy, sickle cell disease, and/or type 2 diabetes)I am an essential non-healthcare worker (i.e. education sector, food & agriculture, utilities, police, firefighter, correction officers, and transportation)
Should be Empty: