You can always press Enter⏎ to continue
Vaccine Signup UNC
Hi there, please fill out and submit this form.
7
Questions
START
HIPAA
Compliance
1
What's your Name?
*
This field is required.
First Name
Last Name
Previous
Next
Submit
Press
Enter
2
What's your date of birth?
*
This field is required.
-
Date
Month
Day
Year
Previous
Next
Submit
Press
Enter
3
What's your Phone Number?
*
This field is required.
Please enter a valid phone number.
Previous
Next
Submit
Press
Enter
4
What's your Email?
*
This field is required.
example@example.com
Previous
Next
Submit
Press
Enter
5
Which vaccine would you like to get at your appointment?
*
This field is required.
According to the CDC, current guidance has shown that COVID-19 vaccines "can be coadministered with other vaccines, including influenza vaccines."
Flu
Moderna (Spikevax) COVID 24/25 (If available at the time of the clinic)
Shingles (Shingrix 50+)
Previous
Next
Submit
Press
Enter
6
Appointment
*
This field is required.
Please chose a time slot to get your vaccine(s)
Previous
Next
Submit
Press
Enter
7
Please upload your insurance card (Front only)
*
This field is required.
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
Cancel
of
Previous
Next
Submit
Press
Enter
Should be Empty:
Vaccine Signup UNC
[Edit]
Question Label
1
of
7
See All
Go Back
Submit