COVID-19 Vaccines

COVID-19 Vaccines
Legal Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Home Phone Number
Please enter a valid phone number.
Mobile Phone Number
Please enter a valid phone number.
Email
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Race*

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhitePrefer not to answer
Ethnicity*

Hispanic or LatinoNot Hispanic or LatinoPrefer not to answer
Gender*

MaleFemalePrefer not to answer
Preferred Vaccine*

2024-25 Moderna Spikevax
Have you previously received a dose of COVID vaccine?*

YesNo
If yes, please choose how many doses you have received? ** Please note: We follow current NC DHHS recommendations for vaccination. Please call the pharmacy to verify if you qualify for a booster vaccine if you have questions. **

First dose of Pfizer vaccineTwo or more doses of Pfizer vaccineFirst dose of Moderna vaccineTwo or more doses of Moderna vaccineFirst dose of Johnson & Johnson
Has is been at least two months since your last COVID vaccine dose?*

YesNo
Appointment*
Please note: Vaccine appointments may be canceled or rescheduled by pharmacy staff based on vaccine availability and clinical criteria. You will be asked to provide identification and insurance information, if available, at your vaccine appointment. If you have received COVID vaccine(s) previously, please bring your vaccine card so that we may update your card. Thank you.
Would you also like a Flu Vaccine during your COVID immunization visit?

YesNo
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