Covid vaccine appointment scheduling

Covid vaccine appointment scheduling

(for Covid vaccinations at WinnMed Pharmacy)
Full Name*

First NameLast Name
Date of birth*

MonthDayYear
(Covid vaccine approved for 12 years of age or older)
Contact Number*
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please pick a date and time for your vaccine appointment: *
Please write your appointment date and time down; for security reasons no reminder message is sent.
For the Covid shot- which arm do you want to use?*

Left ArmRight Arm
Do you want to get the flu shot as well?*

YesNo
If yes- what arm do you want the flu shot in?

Left ArmRight arm
Should be Empty: