COVID-19 Vaccine Appointment Booking @ Hamilton Pharmacy

1
Have you tested positive for COVID-19 within the past 14 days?* This field is required.
YESNO
2
Booking Date/TimeIf the date you would prefer is not available, you may skip this question to be added to the waitlist.
3
Waitlist preferred date* This field is required.You will be added to the waitlist for the date specified Date format is day/month/year.
Date
Day
Month
Year
4
Vaccine Type* This field is required.
Pfizer/BioNTech 1st dose
Pfizer/BioNTech 2nd dose
Pfizer/BioNTech 3rd dose / Booster 1
Pfizer/BioNTech 4th dose / Booster 2
Pfizer/BioNTech 5th dose / Booster 3
Moderna Bivalent 3rd dose / Booster 1
Moderna Bivalent 4th dose / Booster 2
Moderna Bivalent 5th dose / Booster 3
5
Date of Birth* This field is required.Date format is day/month/year.
Date
Day
Month
Year
6
Are you immunocompromised and/or a health care worker?* This field is required.
YESNO
7
Please provide a brief description of how you're immunocompromised and/or what your position is as a health care worker* This field is required.
8
NOTICEPlease note that priority for the Moderna bivalent vaccine is given to individuals who meet any of the following conditions: - 50 years of age or older - Immunocompromised - Related chronic health problems (asthma, heart or lung disease, diabetes, hepatitis, renal disorder, sickle cell anemia) - Healthcare or essential worker As a result, your appointment will be booked tentatively but may be cancelled/rescheduled to accommodate any individuals who meet the above conditions. Do you acknowledge and agree to these conditions?
YESNO
9
Date of your {previousDose} COVID-19 vaccination doseYou may skip this question if you don't have this info available at this time. Please note that it must be before {latestPrevious}. Date format is day/month/year.
Date
Day
Month
Year
10
Was your {previousDose} dose administered overseas (not in Bermuda)?* This field is required.
YESNO
11
Select the manufacturer of your {previousDose} dose* This field is required.
Pfizer / BioNTech
AstraZeneca
Serum Institute of India
Janssen / Johnson & Johnson
Moderna
Sinopharm / BIBP
Sinovac
12
Name* This field is required.
First Name
Middle Name
Last Name
13
Email* This field is required.
example@example.com
14
Phone Number* This field is required.(eg - 1 441 2927986)
Country Code
Area Code
Phone Number
15
Physician's Name* This field is required.
16
Address* This field is required.
Street Address
Street Address Line 2
City / Parish
State / Province
Postal / Zip Code
Bermuda
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
17
Have you ever had a severe allergic reaction (Example: Anaphylaxis) in the past requiring an EpiPen or hospitalization?* This field is required.
YESNO
18
Have you ever had a serious reaction after receiving a vaccination?* This field is required.
YESNO
19
Please describe the nature of your reaction(s) including any potential triggers of your allergies* This field is required.Enter one per line
20
Comments / Questions
21
Please verify that you are human* This field is required.
22
Sorry, you're not eligible for a COVID-19 vaccination at this time.
23
Previous dose name
24
Booking Date
Date
Year
Month
Day
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Hour
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Minutes
AM
AM
PM
25
Appointment type
26
Latest Previous dose allowed
Date
Day
Month
Year
27
Vaccine Administrator
28
Submission Date
Date
Day
Month
Year
29
Age
Should be Empty: