COVID-19 Immunization Screening and Consent Pre-Registration Form*
Please fill out the form below.
When appointments are available we will email those eligible (at pharmacies) a link to book an appointment.
Hi! Thank you for your interest in receiving the COVID-19 vaccination. Please complete this form to pre-register for the COVID-19 Vaccination. Please make sure that you are eligible to receive the vaccination according to local state vaccinate rollout plans. For reference please refer to:
NY Vaccine Eligibility NJ Vaccine Eligibility
We will contact those eligible according to relevant state guidelines and pre-registered by email to book appointments as they become available. Appointments for the COVID-19 vaccine will be on a first come, first served basis to those eligible. Due to the limited availability, please note that pre-registering does not guarantee an appointment.
Prior to your appointment, please review the vaccine information Fact Sheet in the links below (to conserve paper, hard copies will only be available upon specific request).
Moderna Fact Sheet for Recipients and Caregivers
Johnson & Johnson Fact Sheet for Recipients and Caregivers