Thank you for taking this important step. Currently, we do not have any vaccine in stock. You can fill out this form and join our standby wait list. We may or may not contact you. Please do not call the pharmacy. We cannot make any reservations or appointments. Feel free to keep checking daily for appointment slots. By filling out this form, it does not guarantee you will get the vaccine from Super Health Pharmacy. When you see appointment slots available, that means we have vaccine in stock.

I have been given a copy and have read, or have had explained to me, the information in the FACT SHEET for he COVID-19 vaccine. I understand the FDA has authorized the emergency use of the COVID-19 vaccine, which is not an FDA-approved vaccine. I have had the chance to ask questions that were answered to my satisfaction.

I understand the significant known and potential risks and benefits of the COVID-19 vaccine as explained in the FACT SHEET and that some potential risks and benefits may remain unknown, and I REQUEST THE COVID-19 VACCINE BE GIVEN TO ME.

I understand the COVID-19 vaccine requires 2 doses given 4 weeks apart. If this is my first dose of the COVID-19 vaccine, I intend to receive a second dose of the same vaccine in accordance with the timeframe specified in the Fact Sheet to complete the vaccination series.

I agree to stay in the vaccine administration area for fifteen (15) minutes (or longer if indicated by the vaccine administrator) after receiving my vaccination to ensure that no immediate adverse reactions occur, and I understand that if I experience any adverse reaction, it will be my responsibility to follow up with my primary care physician.