COVID-19 Vaccine Request Form
Please enter a valid phone number.
Street Address Line 2
State / Province
Postal / Zip Code
Or put N/A if no insurance - COVID vaccines are no cost to patient regardless of insurance status
Health and Medical History
Please check the statements that apply
I am an essential worker
I am age 65+
I have a severe chronic condition
I am otherwise healthy
I have an illness in which I am considered high risk
Please list any chronic health conditions or illnesses
Please indicate all health issues that are considered within the risk group
If essential worker or other is checked, please provide details below
Have you been diagnosed with COVID-19?
If yes, please provide month/year of diagnosis
I hereby declare that all the given information is accurate.
Should be Empty: