COVID-19 Vaccine Waitlist

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2

Have you received you first dose of COVID-19 vaccine?

YESNO

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If yes, select which COVID-19 vaccine you received for your first dose?

Pfizer COVID-19 Vaccine

Moderna COVID-19 Vaccine

I Do Not Remember

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Are you a member of one of the following groups?* This field is required.Groups based on CDC/ACIP recommendations for Phase 1b/1c COVID-19 vaccine distribution

Healthcare Workers

Adults greater than 70 years of age

Higher Education Staff

Daycare Staff

Other

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Name* This field is required.

First Name

Last Name

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Phone Number* This field is required.

Area Code

Phone Number

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Email* This field is required.Email will be used to confirm appointment time and other information regarding COVID-19 testing.

example@example.com

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Consent to Notify: I consent that Southern Pharmacy may contact me via email and/or sms message using the information provided. Contact information may include COVID-19 vaccine availability, COVID-19 vaccine appointment reminders, and other healthcare information.

View the Southern Pharmacy privacy policy here

Please click SUBMIT to verify consent