Rose Drug of Russellville CV19 Sign Up
This will allow us to get a list of patients that are interested in getting the COVID 19 vaccine when it becomes available. Your email, if provided, will be used to schedule your COVID 19 vaccine appointment. Alternatively, if an email is not provided we will send you a text message so please provide a mobile phone number if possible.
Name
*
First Name
Middle Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Type a question
Meatpacking Plant Worker
School/College Faculty or Staff
Manufacturing Workers
Public Transit Worker
Grocery Store Worker
Jail/Detainment Facility Worker
Agriculture Workers
Postal Worker
State Correctional Worker
Healthcare worker
Truck Driver
Essential Government Employee
Food Service
Pharmacy Staff
High Risk Medical Condition (Chronic Disease)
Daycare Employee
First Responder
65+ Years Old
Education
Food and Agriculture
People with intellectual or developmental disability
Houses of worship
Manufacturing
Signature *By signing below you are confirming the information stated above is truthful and honest in nature.
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