The Former Best Buy BuildingHudson Valley Mall, 1300 Ulster Ave, Kingston, NY 12401
CLINIC DATE AND TIME
Thursday 3-18-21 from 3pm-7pm
IF YOU ARE COMPLETING THIS ON BEHALF OF SOMEONE
Please ask them to get a PEN and PAPER because they have to write down a unique ID number, their appointment information, and instructions for clinic day
This is step 1 of 3. Here are the steps that need to be completed for each patient:
This entire process should take 5-10 minutes. Please do not share the link to this form with anyone; it is only for the people you have been assigned.
GENERIC CLINIC TEXT
This clinic is currently reserved for patients 60 and over OR teachers for FIRST DOSES of Moderna COVID Vaccines.
NYS DOH's Definition of Teachers (as per their guidance found here)
P-12 school (public or non-public) or school district faculty or staff (includes all teachers, substitute teachers, student teachers, school administrators, paraprofessional staff, and support staff including bus drivers)
Contractor working in a P-12 school or school district (including contracted bus drivers)
Licensed, registered, approved or legally exempt group childcare
In-person college faculty and essential in-person staff
IMPORTANT NOTE ABOUT THE SIGNUP PROCESS:
Due to the overwhelming volume, we are unable to assist with technical difficulties. If it doesn't work out today, you WILL get a shot soon. Deep breath.
We are not accepting any phone calls regarding COVID support. If you have questions, please email firstname.lastname@example.org. Please do not call the store.
STANDBY LIST TEXT
We are required to maintain a standby list to ensure no COVID vaccine doses are wasted.
This does not guarantee a spot in an upcoming clinic.
READ THIS SENTENCE CAREFULLY: If you did not receive this link DIRECTLY from Neal, you will be removed from this list permanently and the person who shared the link to you will be removed as well.
You are being sent this because you are eligible to receive the vaccine as per NYS now and I believe you can get to our clinic with very little notice.
Filling out this form will ensure we have all necessary information.
After you receive confirmation, follow the instructions to be prepared if we contact you on clinic day to come get a dose.
If you have remaining questions, please email our Vaccine Support: email@example.com.
You are not eligible for this clinic.
This clinic is for the first dose of patients 60 or older or teachers (as defined by NYS DOH) who have not been treated with COVID antibodies in the last 90 days or have not had any other vaccine within 14 days.
When entering your name, do NOT write middle initials. PLEASE write any suffix (Jr, III).
In an attempt to reduce paper waste, all legally required documents must be downloaded here. Very limited copies will be available on clinic day.
If you are completing this on behalf of someone else, please download these documents and email them to the patient.
If they do not have email, limited copies will be available for them on clinic day.
All copies are available at drneal.co/vax.
Click this to download the Emergency Use Authorization for the Moderna Vaccine.
Click this to download the Notice of Privacy Practices
Click this to download the CDC vSafe app flyer
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA), a copy of which I was provided with this registration.
I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.
I certify that I have received, read, and understand the Emergency Use Authorization.
I certifty that I have received the Notice of Privacy Practices.
I certify that I have received the CDC vSafe informational flyer.
Please type your full name in the box below. You agree your typed full name represents your electronic signature is the legal equivalent of your manual signature on this form.
**Vaccine supply is limited. Please keep your appointment.**
Additionally, due to vaccine requirements; we may call you to see if you can come earlier, later or to a nearby location.
If you miss an appointment, no doses will be held to guarantee your dose in the future.
By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.