COVID-19 Vaccine Appointment

COVID-19 Vaccine Appointment

We're helping our community schedule appointments to receive the COVID-19 vaccine. If you wish to receive help, please fill out this form and we'll reach you back as soon as possible. We appreciate your patience as we're receiving a high volume of requests.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Preferred Language*
Preferred Appointment Location (Please notice that we cannot guarantee appointments availability at your preferred location)*

Have you received another vaccine within the last 14 days?*

YesNo
Are you currently acutely ill from known SARS-CoV-2 infection?*

YesNo
Do you have a known history of a severe allergic reaction to a component of the COVID-19 vaccine?*

YesNo
In the past 90 days have you received monoclonal antibodies or convalescent plasma as part of COVID-19 treatment?*

YesNo

In the past have you had a severe allergic reaction to a vaccine or injectable therapy (intramuscular, intravenous, or subcutaneous)?*

YesNo
Are you currently pregnant or breastfeeding/lactating?*

YesNo
Before you receive the vaccination, it is strongly recommended that you consult with your healthcare provider to make an informed decision.

Please compete below. Your ID will be checked at the appointment check-in.
I, First Name Last Name promise that the information provided above about my eligibility for vaccination is accurate.

At this time, vaccinations have been prioritized and targeted for the groups indicated above only. As the COVID-19 vaccination eligibility and initiative expands, more information will follow.
At this time you are not eligible to receive the COVID-19 vaccine.
If you do not live or work in New York City, and you are not already a patient of NYC Health + Hospitals, please click https://covid19vaccine.health.ny.gov/what-you-need-know to find a vaccination site in your home county.
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