WAIT LIST FOR BOOSTER COVID 19 VACCINATION
Name
First Name
Last Name
Gender
Male
Female
Date of Birth
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Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Do you qualify for Booster currently? If so would you be deemed "vulnerable" (65+, comorbidities, immune-suppressing diseases or on immune-suppressing medications) *
Yes
No
Booster for everyone else!
Yes
No
Did you get your COVID Vaccine thru Hague Pharmacy at CHKD?
Yes
No
Your Signature
Date Signed
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Month
-
Day
Year
Date
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