Language
English (US)
Español
Notification/Wait List - Including Fall 2023 COVID-19 Vaccines
Thank you for your interest. The new formulation of the COVID-19 vaccine was approved on Sep 11, 2023. If you do not see the vaccine you want as available on our appointment scheduling form, please fill out this page to express interest in its availability. Please specify in notes which vaccine you wish to be notified about (Pfizer, Moderna, etc.). We'll contact you as soon as we have scheduling availability. Appointments can be made on our schedule a vaccination page. Thank you!
Name
*
First Name
Last Name
Medical Condition Comments (optional)
Phone Number (Note - this will be primary contact method for individual contacts when a small number of slots need to be filled, such as end of night unused doses. When multiple vaccination slots open up, we will use email as primary contact method. )
*
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Email (Note - this will be the primary means of notification when multiple vaccination appoitments are available)
*
example@example.com
Gender
*
Female
Male
What is the age of person to be vaccinated?
*
Vaccine preference / Additional Notes / Remarks
Thank you for choosing Willey Pharmacy! We are conveniently located at 3625 Wrangle Hill Road, Bear, Delaware 19701, behind the new WaWa at Red Lion Hundred, at the corner of Route 72 and Route 71, just off Route 1.
Save
Register
Which Vaccination Phase are you a part of? Note: The State of Delaware's Vaccine rollout plan has different phases available to different types of providers. Below are phases currently available for vaccination at Delaware Pharmacies, including Willey Pharmacy. If you are not one of these phases, please select the next drop down list for other priority lists.
Please Select
Persons 5-11 Years of Age (Parental Consent must be given in writing and parent/guardian must be present)
Archive Field - do not enter data
Please Select
Archive field
Please Select
High Risk Medical - Obesity
High Risk Medical - Severe Obesity
High Risk Medical - Diabetes
High Risk Medical - COPD
High Risk Medical - Heart Condition
High Risk Medical - Chronic Kidney
High Risk Medical - Cancer
High Risk Medical - Smoking
High Risk Medical - Solid Organ Transplant
High Risk Medical - Sickle Cell Disease
High Risk Medical - Intellectual/Developmental Disabilities
High Risk Medical - Severe and Persistent Mental/Behavioral Health Conditions
Moderate Risk Medical - Asthma (Moderate-to-Severe)
Moderate Risk Medical - Cerebrovascular Disease
Moderate Risk Medical - Cystic Fibrosis
Moderate Risk Medical - Hypertension
Moderate Risk Medical - Immunocompromised State
Moderate Risk Medical - Neurologic Conditions
Moderate Risk Medical - Liver Disease
Moderate Risk Medical - Overweight
Moderate Risk Medical - Pulmonary Fibrosis
Moderate Risk Medical - Thalassemia
Archive field, do not complete.
-
Month
-
Day
Year
Date
Are you a Delaware Resident?
*
Yes
No
Occupation - Note: If occupation places you into certain phase, employer provided proof may be required (such as 1A letter, essential worker letter, etc.)
Have you had a first dose of COVID-19 vaccine?
Yes
No
Who is your Employer and what state do you work in?
If you've had a first vaccine dose, which brand was it? NOTE: To date Willey Pharmacy has exclusively received Pfizer.
Pfizer
Moderna
Johnson & Johnson
COVID-19 Vaccination History
Have you received passive antibody treatment for COVID-19 in the past 90 days?
Yes
No
I hereby declare that all the given information are accurate.
Yes
If you had a first vaccine dose, which date was it? Pfizer is due in 21 days, Moderna is due in 28 days
-
Month
-
Day
Year
Date
Should be Empty: