KTA Waikoloa Village Pharmacy Sign Up Form for Scheduling a 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.
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.