Hometown COVID Survey

Appointment Request Form

Note: the information provided within is intended to aid Hometown Drug staff in providing the COVID-19 vaccine to our patients and community members in an organized (and more importantly, SAFE) fashion. **All potential recipients should fill out a separate form**
First name*
MUST SUBMIT NEW ENTRY FOR EACH INDIVIDUAL PATIENT **ONLY ONE ENTRY PER PERSON WILL BE ACCEPTED.**
Last name*
Date of Birth*

MonthDayYear
MaleFemaleN/A
Phone number*
Please use the same phone number for all patients you wish to be the primary point of contact for (i.e. children, elderly family members, etc.)
Email Address
Best time of day to reach you?
Do you have health insurance? (This will NOT prevent you from receiving the vaccine)

YESNO
Help us determine which vaccination group you belong in by SELECTING ALL THAT APPLY TO YOU:

HOSPITAL WORKER (IN DIRECT CONTACT WITH PATIENTS) [1A]LONG-TERM CARE STAFF (ASSISTED LIVING, NURSING HOME, STATE HOME) [1A]EMS PROVIDER (WHO ENGAGE IN 9-1-1 EMERGENCY SERVICES) [1A]HOME HEALTH CARE WORKER (INCLUDING HOSPICE CARE) [1A]RESIDENT AT A LONG-TERM CARE FACILITY [1A]OUTPATIENT HEALTH CARE STAFF [1A2]FREESTANDING EMERGENCY MEDICAL CARE FACILITY/URGENT CARE EMPLOYEE [1A2]COMMUNITY PHARMACY STAFF [1A2]PUBLIC HEALTH AND EMERGENCY RESPONSE STAFF (WITH DIRECT COVID VACCINATION AND TESTING CONTACT) [1A2]LAST RESPONDER (MORTUARY OR DEATH SERVICES) [1A2]SCHOOL NURSE [1A2]65 YEARS OR OLDER [1B]AGE 18 YEARS AND OLDER WITH AT LEAST ONE CHRONIC MEDICAL CONDITION (INCLUDING BUT NOT LIMITED TO: CANCER, CHRONIC KIDNEY DISEASE, COPD, HEART CONDITIONS, SOLID ORGAN TRANSPLANT, PREGNANCY, SICKLE CELL DISEASE, TYPE 2 DIABETES) [1B]TEACHERNONE OF THE ABOVE APPLY
Additional Information For Us:
Disclosure*

I understand this tool is intended only to allow patients to provide their availability to receive a COVID-19 vaccination from Hometown Drug.
Disclosure*

I understand this is NOT an appointment confirmation/guarantee. **Hometown Drug staff will contact you directly to discuss a designated time frame for which you can receive your vaccine. Appointment time frames will be selected based on the information provided on this form.**
Disclosure*

I understand ALL appointment time frames are tentative and subject to change based on vaccine and staff availability at the discretion of Hometown Drug staff. **Inability to accept a spot during an "assigned" time frame will NOT prevent you from receiving an appointment time frame or vaccination; specific time frames will be discussed when Hometown Drug staff contacts a patient to discuss the availability provided on this form.**
Disclosure*

I understand completion of this form does NOT qualify me to receive the COVID-19 vaccine. **The qualification of each individual patient will be determined using current and up-to-date CDC guidelines and recommendations at the sole discretion of the Pharmacist-on-duty.**
Disclosure*

I give permission to Hometown Drug and its staff to contact me to discuss the COVID-19 vaccine and potential time frames to receive the vaccine
Signature
Should be Empty:

Appointment Request Form