COVID-19 Vaccine Wait List Sign-up Form

COVID-19 Vaccine Wait List Sign-up Form

Because of the short supply, we are currently on a waitlist for COVID-19 vaccination. Please complete this form to be added to the waitlist. -Thank you!
Name *

First Name Last Name
Email
example@example.com
Phone Number *
Please enter a valid phone number. (Mobile Preferred)
Date of Birth *

Month Day Year
Have you ever been seen at this healthcare facility? *

Yes, I have. No, I am a new patient.
Pharmacy Location *
Priority Groups (select all that apply) *

Health care workers Long term care facility resident Age 65+ Living in congregate settings (Group home, corrections, treatment centers, etc.) Two or more high risk medical conditions One high risk medical condition Child care worker Workers employed by preschool or K-12 grade National Guard Grocery store workers Public safety answering phones (911) Public transit including bus, taxi, ride-share Blood bank workers Information technology Other essential workers NOT able to work from home Phase 2 - all others age 16+ not previously covered
High Risk Condition (select all that apply) *

Cancer Chronic Kidney Disease COPD (Chronic Obstructive Pulmonary Disease) Heart Conditions, such as heart failure, coronary artery disease, or cardiomyopathies Immunocompromised state (weakened immune system) from solid organ transplant Obesity (body mass index {BMI} of 30kg/m2 or higher) Pregnancy Sickle Cell Disease Smoking Type 2 Diabetes Mellitus NOT APPLICABLE Other
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