C&D Drug Store Covid-19 Vaccine Wait List

C&D Drug Store Covid-19 Vaccine Wait List

Please do not sign up on this list if you have previously called C&D Drug Store and put your name on the wait list. Thank you!
Name

First Name Middle Name Last Name
Date of Birth

Month Day Year
Date
Address

Street Address

City State

Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Employer (Add where you work or put retired or not working)
List any details such as essential employee, volunteer services, medical conditions, etc. that would affect which phase of the vaccination roll out you qualify for.
Please Note:

C&D Drug Store reserves the right to refuse to vaccinate based on false information provided, being late to a scheduled appointment, or refusal to provide required documents or information to fill prescription. We will contact you to schedule an appointment as soon as a dose of vaccine becomes available for you. We appreciate your patience during this time and look forward to serving you!
Should be Empty:

Please Note: