COVID-19 Vaccine Clinic Email Notification Sign-Up

Completing this form does not assure of receiving the COVID-19 vaccine. It also doesn't guarantee that you will be added to the waitlist.

Please be aware that the supply of the vaccine is only limited therefore you cannot walk-in in the clinic and a reservation and appointment must be scheduled.

Our clinic is busy nowadays, we recommend you not to call asking for a slot. We will contact you when a slot is available.

Name

First NameLast Name

Age

Gender

Date of Birth

Date

Email

example@example.com

Primary Phone No.

Please enter a valid phone number.Format: (000) 000-0000.

Secondary Phone No.

Please enter a valid phone number.Format: (000) 000-0000.

Best time to contact you

Hour Minutes

AM/PM Option

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Are you frontline essential worker?

What is your position/title?

Where are you working?

Do you have any of the following condition? Select all that apply or don't select if you don't have any.

Would you like to be listed when a slot will be available or when someone requested for cancellation?

Thank you for completing the form. Have a great one and stay safe!