COVID Vaccine Waiting List

COVID Vaccine Waiting List

COVID-19
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.
Full Name (As it appears on your Medicare card or insurance card) *

First Name Last Name
Birth Date *

Month Day Year
Date
Age
Do you have Medicare or Medicare Advantage Plan? *

Yes No
Medicare Number if applicable
Format:
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Sex *

Female Male
Cell Phone Number
Email (prefered method, initial notification will be sent by email)
example@example.com
Screening Questions

Check all that Apply
Comorbidities

No Comorbidities Asthma Cancer Cerebrovascular Disease Chronic Kidney Disease COPD Cystic Fibrosis Down Syndrome Diabetes Heart Conditions High Blood Pressure Immunocompromised State (BMT, HIV, corticosteroids, etc) Liver Disease Neurologic Conditions (Dementia, etc) Organ Transplant Obesity (BMI > 30) Severe Obesity (BMI > 40) Pregnancy Pulmonary Fibrosis Sickle Cell Thalassemia
Additional Phase Screening

First Responder Healthcare worker providing direct or outpatient care Staff or Resident in congregate locations or worksite Pre - K 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 Hospital Discount Pharmacy

Yes No I already fill my prescriptions at Hospital Discount Pharmacy
If you have already received dose #1, when did you receive it?
If you have already received dose #1, did you receive the Moderna or Pfizer vaccine?
Should be Empty:

COVID Vaccine Waiting List

Screening Questions