COVID Vaccine Consent Form

COVID-19 Vaccine Pre Registration Form Facilities

* Please fill out the required details below
DISCLAIMER: Filling out this form does not guarantee your chances of getting the COVID-19 vaccine. Once we have more information, we will contact you personally. Thank you for your interest and stay safe.
First and Last Name of Contact Representative: *

First Name Ml Last Name
Phone Number: *
Position: *
Email: *
Facility Name: *
Full Address of Facility: *

Street Address Line 2
Facility Type (LTC, SNF, Group Home, School etc.) *
Number of Employees *
Number of Patients/Residents *
How many nurses will be helping onsite? *
How many Epipen do you have onsite? *
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.
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COVID-19 Vaccine Pre Registration Form Facilities