Covid-19 Vaccine Waiting List
Please complete the following pages to join our waiting list. We currently don't know when we will receive the vaccine, nor do we know how much we will receive. If you are able to get the vaccine elsewhere before we contact you, you should get it.
Have you received a Covid Vaccine?
Pfizer (Stop here, we will not receive Pfizer vaccine in the next 8 weeks)
What date was your first Dose?
Full Name (As it appears on your Medicare card, if you have Medicare. For example, Buddy Johnson, Medicare card says William Johnson Jr., you would enter William Johnson Jr. If you don’t have Medicare, simply enter your name)
Do you have Medicare or Medicare Advantage Plan?
Street Address Line 2
State / Province
Postal / Zip Code
Cell Phone Number (receives text messages)
Have you had a Flu Shot for 2020-2021 (covered 100% by your insurance)?
Have you had a Shingrix (Shingles) Vaccine (50 years and older)? Covered by insurance subject to deductible
Have you had a Prevnar-13 vaccine (pneumonia) ? (Covered my Medicare)
Have you had a pneumovax-23 vaccine (pneumonia)? (Covered by Medicare)
Check all that Apply
Chronic Kidney Disease
High Blood Pressure
Immunocompromised state (BMT, HIV, corticosteroids, etc)
Neurologic Conditions (Dementia, etc)
Obesity (BMI > 30)
Severe Obesity (BMI > 40)
Other Screening Questions
Check any that apply
Additional Phase Screening
Healthcare worker providing direct or outpatient care
Staff or resident in congregate locations or worksite
PreK - 12 teacher or support staff
Public Health staff
Senior State, County, or City government leader/elected official
Phase Screening Continued
Teacher or staff at daycare
Professor or staff at College/University
Essential business/industry personnel
I am interested in switching my prescriptions to Clyde Pharmacy
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