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.Format: (000) 000-0000.
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?
Are you currently acutely ill from known SARS-CoV-2 infection?
Do you have a known history of a severe allergic reaction to a component of the COVID-19 vaccine?
In the past 90 days have you received monoclonal antibodies or convalescent plasma as part of COVID-19 treatment?

In the past have you had a severe allergic reaction to a vaccine or injectable therapy (intramuscular, intravenous, or subcutaneous)?
Are you currently pregnant or breastfeeding/lactating?
Before you receive the vaccination, it is strongly recommended that you consult with your healthcare provider to make an informed decision.

Ambulatory Care Setting Details
Ambulatory Care Setting Occupation/Role
Please Further Specify Role
Date of Birth

MonthDayYear
Date
Enter Other Type of Work
Employer/Work Place Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Employer/Work Place Name

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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