Pediatric Covid Waitlist Application
For individuals aged 6 months - 11 years wishing to receive the covid vaccination. ***Availability subject to supply, demand, insurance, and pharmacist discretion.
Contact Name (name of parent/guardian)
*
First Name
Last Name
Contact Email
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient's Name
*
First Name
Last Name
Patient's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient's Address (for insurance look up)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient's Insurance Company (pharmaceutic benefits - enter RxBIN if not sure)
Submit
Should be Empty: