Johnson and Johnson Covid Vaccine
4439 County Club Rd. Statesboro, Ga 30458 Phone: 912.489.7979.
Date of Birth
Street Address Line 2
State / Province
Postal / Zip Code
Which of the following qualifies you for a vaccine under the state of Georgia requirements? (These requirements begin on March 8, 2021)
Over the Age of 18
IF YOU DO NOT HAVE YOUR MEDICARE ID, PLEASE USE YOUR SOCIAL. THIS IS OPTIONAL
Are you a Georgia resident or do you work in the state of Georgia?
I attest that I have not had any other vaccine in the past 14 days
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