COVID-19 Vaccine Waitlist KTA Puainako Pharmacy

KTA Puainako Pharmacy Sign Up Form for Moderna COVID-19 Vaccine

A new submission needs to be completed for each individual.

Individuals in phase 1a, 1b and 1c and over the age of 70 may sign up here. A pharmacy staff member will contact you to schedule an appointment.

Please make sure to fill out the entire form until you get to the last page that says "Thank you!" You should also recieve an email confirmation from Jotform.

Please be patient as we will work through this list based on the current priority group.

Name *

First Name Last Name

Birthdate *

Date

Cell Phone Number *

Area Code Phone Number

Email

example@example.com

Please indicate which category you fall into: *

Healthcare Worker Age 70 and older Frontline Essential Worker: grocery, food production, agriculture, fire fighter, police officer, education, postal service, public transit Department of Health Foster/ARCH/DDD patient or caregiver Essential Workers: restaurants, food suppliers, financial institutions, mechanics, electrical contractors, construction, hospitality

If you are a healthcare worker or frontline essential worker, please indicate your occupation and employer below.

Occupation

Employer

Notes