Vaccine

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Do you fall into one of the following eligibility groups?* This field is required.- Healthcare worker - Agriculture or food worker - Education or child care worker - Emergency service worker - Long-term care resident - 50 years of age or older - Age 18 to 49 with severe health/medical condition that puts you at a very high risk for morbidity and mortality from COVID-19 - Over 16 years of age If you do NOT fall into one of the above groups, please check back at a later date for eligibility.
Yes, I am eligible
2
Are you scheduling for your SECOND shot?
YESNO
3
For which dose are you scheduling for?
1st
2nd
3rd / Booster
4
Please make sure to book AT LEAST 4 weeks from date from your previous dose* This field is required.
Yes, I understand
5
What vaccine are you interested in?* This field is required.
Moderna
6
Name* This field is required.
First Name
Last Name
7
Date of Birth* This field is required.
8
Gender* This field is required.
Male
Female
Other
9
Mobile Phone Number* This field is required.
10
Cleaned Phone Number* This field is required.
11
Email Address
example@example.com
12
Home Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
13
Photo of ID* This field is required.Driver's License, School ID, Passport, Green Card, etc.
14
Photo of Driver's License / Passport* This field is required.NO SELFIES PLEASE. US or state government issued ID only. Social Security Card acceptable for minors.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
15
Do you have health insurance?* This field is required.
YESNO
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Photo of Insurance Card* This field is required.
17
Photo of Insurance Card* This field is required.Please click "Browse Files" and take a photo
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Select files to upload
Max. file size: 10.6MB
Cancelof
18
ID/Driver's License/Passport number* This field is required.
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Select an Appointment* This field is required.
20
Source
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Terms and Conditions* This field is required.By continuing, you agree that: * 1) You are 18 years old or older or 2) the parent or legal guardian of a minor patient or 3) the legal guardian of the patient * You're not experiencing severe symptoms such as severe shortness of breath, continuous pain or pressure in the chest, or persistent fever greater than 102ºF. If you're experiencing severe symptoms, please seek medical attention immediately. * You agree to receive email and/or SMS communications from TLC Xpress that contain appointment information for and/or about you, the minor patient, or dependent patient.
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noreply@jotform.com* This field is required.
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