Boalsburg Apothecary Covid 19 Vaccine Waiting List
Please fill out the following information below to be added to your COVID 19 vaccine waiting list. We are currently vaccinating people in Phase 1A. Our vaccine supply is determined by the CDC and PA Dept. of Health. Vaccine is in short supply and we are working very hard vaccinate everybody as quickly as possible as soon as we receive vaccine. Someone will contact you to schedule an appointment once we have more vaccine on hand.
Name
First Name
Last Name
Date of Birth
Example: January 1, 2020
Phone Number
If you are between the age of 18 & 64, please list your chronic health conditions that put you into phase 1A ( Example, Heart disease, Kidney disease, cancer, COPD, BMI >30, autoimmune disorders )
Email
example@example.com
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Submit
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