4/8/21 COVID Vaccine Clinic Signup-STEP1
Please read this entirely and fill out the required details below. This form is HIPAA Compliant.
VACCINES DOSES AVAILABLE: 100
Attn: You received your link to sign up for your Covid Vaccine at Sunshine Pharmacy because you registered on our vaccine waitlist. DO NOT SHARE YOUR LINK WITH OTHERS.
As per NYS, we will comply with their mandate of social equity and fair distribution of the vaccine. To comply, we currently have a waitlist and we are only going to honor the appointments of individuals on that waitlist.
Sunshine Pharmacy reserves the right to cancel any appointment if we find that the individual bypassed our waitlist. If you did not sign up for our waitlist, please click here to sign up for our waitlist.

*One More Thing*

This vaccine is for the Johnson & Johnson Vaccine. This is a 1 Dose Regimen.
YOU DO NOT NEED A 2ND DOSE

If you agree to the information you have read above, please proceed with completing this submission process.
This clinic is currently reserved for patients 60 and over or school faculty and staff
This is a TWO PART submission process.
STEP 1: Fill out this scheduling form and hit SUBMIT.
STEP 2: Take a deep breath; you got a spot! Fill out the form in STEP 2 to finalize your submission.
Which community group assisting people to register for the vaccine do you represent?*
White Plains Youth Bureau El Centro Hispano Thomas Slater Center YWCA Not Applicable
Date of Birth*
Month Day Year
Please enter your Date of Birth
What dose of COVID-19 vaccine will this be?*
First Dose Second Dose
Have you been treated for COVID using those fancy antibody treatments in the last 90 days?*
Yes No
Have you had ANY OTHER vaccines in the last 14 days?*
Yes No Other
You are not eligible for this clinic.
This clinic is for the first dose of patients 18 and older, who have not been treated with COVID antibodies in the last 90 days or have not had any other vaccine within 14 days.
Patient Full Name*
First Name Last Name
Email address*
example@example.com
Phone Number*
Address*
Street Address
Apt #
City State
Zip Code
Clinic Appointment*
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.
WHEN YOU HIT SUBMIT, YOUR DOSE WILL BE RESERVED AND YOU WILL THEN COMPLETE THE CONSENT FORM
Clinic Location
Should be Empty:

4/8/21 COVID Vaccine Clinic Signup-STEP1