OVAC- COVID-19 VACCINE Appointment

COVID-19 Vaccination Scheduling
Moderna 18+ Vaccine- Booster at least 5 months after 2nd dose

Moderna 6m-5yo only- Please schedule your second dose between 4-8 weeks after first dose.

Pfizer 5yo+ - Please schedule your second dose between 3-8 weeks after first dose.

Pfizer 6m-4yo Please schedule your second dose between 3-8 weeks after first dose and third dose at least 8 weeks after your 2nd dose.

See chart below:
Are you interested in having an appointment at OVAC Building or in home?

OVAC- 8 Clinton Ave. Ossining NY 10562In home/ Homebound- you must call our building to confirm appointment. At home appointments will not be confirmed via jotform email.
Please choose a Vaccine.*

Moderna Primary (6m-5yo only)Moderna Bivalent (6m-5yo only)Moderna (Bivalent 18+ Booster only)Pfizer Primary Series only (12+ only)Pfizer (Bivalent 12+ Booster only)Pfizer Primary (5-11 only)Pfizer (Bivalent 5yo-11yo Booster only)Pfizer Primary (6m-4yo only)Pfizer Bivalent (6m-4yo only)
Which dose in your series is this?*

FirstSecondThird/ Booster (5+)Booster Bivalent (Pfizer 5yo-11yo Only)Booster Bivalent (Pfizer 12+ only, Moderna 18+ Only)Third Pfizer (6m-4yo only)
COVID-19 Vaccination Schedules
Vaccinating Location: OVAC Building @ 8 Clinton Ave Ossining NY 10562

Please ring door bell at the entrance to the left of the garage doors.
Appointment Date*
Second Dose Appointment Date- Date will not auto populate for proper time rom first dose. Please double check to ensure your second dose appointment is correct. *
Third Dose Appointment Date PFIZER 6m-4yo ONLY- Date will not auto populate for proper time rom first dose. Please double check to ensure your Third dose appointment is correct. *
Name (Nombre)*

First Name (Primer Nombre)Middle NameLast Name (Apellido)
Date of Birth (Feche de nacimiento)*

MonthDayYear
Date
Phone Number (Numero de telefono)*
Please enter a valid phone number.
Email (Correo electronico)*
example@example.com
Street Address (Direccion)*

Street Address

Street Address Line 2

City (Cuidad)State / Province (Estado)

Postal / Zip Code (Codigo postal)
If an extra dose is available or we have a cancellation on any given day would you like to be contacted last minute for a dose?

Yes please use the phone number listed above.No thank you.
I acknowledge that my appointment may need to be changed based on available vaccine doses. OVAC will try its best to allow for ample notice of any changes needed.
Patient or Designee Signature *

Clear
Ossining Volunteer Ambulance Corps Inc.

Limited Service Laboratory PFI: U384 CLIA: 33D2079047 COVID PIN # is 74688
Should be Empty:

COVID-19 Vaccination Scheduling

Vaccinating Location: OVAC Building @ 8 Clinton Ave Ossining NY 10562

I acknowledge that my appointment may need to be changed based on available vaccine doses. OVAC will try its best to allow for ample notice of any changes needed.

Ossining Volunteer Ambulance Corps Inc.