Wester Drug COVID-19 Vaccine Waitlist:
By filling out this form, Wester Drug will have the necessary information to help quickly. Wester Drug will review this information, and when the COVID-19 vaccine is available for you, we will be contacting you to help get vaccinated.
Walk-ins now welcome!
We are currently scheduling appointments! Please check availability on WesterDrug.com Or by going to the following link.
https://hipaa.jotform.com/210334645144145
Patient Information (Vaccine Recipient Information)
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
What is your preferred method of communication/How would you like to be notified that you may schedule an appointment? (You may select multiple choices from the options below)
*
Text
Email
Phone Call
Place of Employment (Employer's Name) *This question may be left blank
Which store (location) do you wish to receive the vaccine through?
*
Muscatine
Wilton
Earliest Available
COVID-19 Phase Questions
Please answer the following questions to help us determine which COVID-19 vaccination phase applies to you.
Are you a healthcare employee or professional (Do you work in any one of the following: hospital, long-term care facility, outpatient clinic, home health care, pharmacy, emergency medical services, or public health)?
Yes
No
Are you a resident of a long-term care facility (skilled nursing facility, assisted living facility, or other residential care)?
Yes
No
Are you an essential worker (Do you work in education, food & agriculture, utilities, police, firefighter, corrections officer, or transportation)?
Yes
No
Do you have a high-risk medical condition (i.e. cancer, chronic kidney disease, COPD, diabetes, heart conditions such as heart failure, coronary artery disease, or cardiomyopathies, obesity (BMI > 30 kg/m2), pregnancy, sickle cell disease, and/or smoking)?
Yes
No
If you have anything additional you wish to share with Wester Drug staff for review please write in the space below. *This question may be left blank
Submit
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