McCann's Pharmacy Covid-19 vaccine wait list
This is just to get on a list for us to call or email once we get vaccine in. Getting on this list does not guarantee that you will get the vaccine. This will give us a better idea of how much vaccine to order from NYS. Please be patient with us as we do everything we can to access vaccine for our community. We will be in touch via phone or email as soon as we have any vaccine to administer. Thanks in advance for your cooperation!
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
date of birth
*
-
Month
-
Day
Year
Date
Are you 30 yrs old or older?
*
Please Select
yes
no
Age?
*
Are you a patient at McCann's pharmacy?
*
Please Select
yes
no
I am Healthcare worker/first responder?
*
Please Select
yes
no
Essential worker?
*
Please Select
yes
no
K-12 teachers and school staff and child care workers?
*
Please Select
yes
no
Submit
Should be Empty:
Now create your own JotForm - It's free!
Create your own JotForm