PLEASE NOTE: You must be 65 or older to submit this pre-registration form
THIS FORM IS COMPLIANT WITH PATIENT PRIVACY LAWS
Thank you for keeping us informed about your healthcare decision.
By filling out this form you allow Pinehurst Medical Clinic to submit you for registration into North Carolina's COVID-19 Vaccine Management System. This does NOT secure an appointment but is the first step towards getting your vaccine. You will receive an email from the COVID-19 Vaccine Management System (Vaccine Management) to complete your registration.
Please allow at least 24 hours to receive a confirmation email regarding your COVID-19 vaccine request form. This is not an appointment. Remember to check your spam folder, as the confirmation email will contain additional information. Please be aware; you have the option to contact vaccination sites to receive your COVID-19 vaccine. https://covid19.ncdhhs.gov/findyourspot