COVID-19 BOOSTER VACCINE SIGNUP
Forest Heights Pharmacy 4439 County Club Rd. Statesboro, Ga 30458 Phone: 912.489.7979.
Date of Birth
Street Address Line 2
State / Province
Postal / Zip Code
Select the type of COVID-19 vaccine you prefer:
Johnson and Johnson
IF YOU DO NOT HAVE YOUR MEDICARE ID, PLEASE USE YOUR SOCIAL.
Drag and drop files here
Choose a file
Enter the date of your last COVID vaccine:
You must wait 14 days after getting another vaccine (ex.Flu shot). Have you had any other vaccines in the past 14 days.
Yes, I have had another vaccine and therefore I am not eligible.
No, I have not had another vaccine
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform