Covid-19 Fast Track Week 6

Covid-19 Fast Track

Be the first to sign up for our next clinic.
Covid-19 Fast Track

Be the first to know when we have our Covid vaccine doses from NYSDOH or from the Federal level. This form helps you sign up for our clinics before they go public. The list also helps us figure out a number of how many doses to order weekly with New York State. Please note that by signing up it does not guarantee vaccination as we still need the vaccine dose to come in from NYSDOH or from the Federal level. If you place your name on this list and have a guaranteed appointment somewhere else, please let us know as soon as possible so we can give the dose to the next patient in line. Thank you for working with us to help end this global pandemic.

The information provided is solely used to help with tracking Covid-19 doses for ordering and as a compilation list for us to set up our Covid-19 Clinics. The information will not be sold or used for anything else.other than Covid related purposes for our establishment.
Patient Name *

First Name Last Name
Mobile Phone Number *
Required. This is how we will get a hold of you for information via text.
Email *
example@example.com
Date of Birth *

Month Day Year
Date
Age: *
Insurance: *
Zip Code
I can be on as an alternate in case of cancelation on days of Covid Clinics
Are you a patient of Young's Pharmacy & General Store?
LTCF (LONG TERM CARE FACILITY) *
I work in Healthcare/EMS/First Responder *
Aged 65 plus *
Frontline Essential Worker *
Have High Risk Medical Condition *
Other Essential Worker (According to CDC Guidelines) *
K-12 teachers and school staff and childcare workers *
Critical workers in high-risk settings—workers who are in industries essential tothe functioning of society and substantially higher risk of exposure *
People in prisons, jails, detention centers,and similar facilities, and staff who work insuch settings *
Should be Empty: