COVID-19 Vaccine Interest Form

COVID-19 Vaccine Interest Form

COVID-19 vaccines are coming soon to our pharmacies! Please fill out the form and we will contact you with more information as it becomes available. Filling out this form does not guarantee you a COVID-19 vaccine.
Name *

First Name Last Name
Date of Birth *

Month Day Year
Phone Number *

Area Code Phone Number
Email *
example@example.com
Which location is closest to you? *
Please select which of the following options apply to you: *

I work in a healthcare setting (i.e. hospital, long-term care facility, emergency medical services, home health care, outpatient clinic, pharmacy, public health, mortuary services, school nurse) I live at a long-term care facility I am 65 years of age and older I have at least 1 chronic medical condition that puts me at high risk for COVID-19 (i.e. cancer, chronic kidney disease, COPD, heart conditions, organ transplant, obesity, pregnancy, sickle cell disease, and/or type 2 diabetes) I am a frontline essential non-health care worker (i.e. police officer, firefighter, corrections officer, food and agricultural worker, postal worker, manufacturing worker, grocery store worker, public transit worker, teachers, child care workers) I am an other essential non-health care worker (i.e. transportation/logistics, water and wastewater, food service, shelter/housing, finance, information technology and communications, energy, legal, media, public safety, public health workers) None of these options apply to me
Should be Empty: