Covid Vaccination - Schedule an Appointment

BrickStreet Vaccine Registration & Scheduler

Flu, COVID-19, Shingles, Pneumonia
Thank you for choosing BrickStreet Pharmacy as your COVID vaccine provider. Our primary goal is to vaccinate as many people as possible both safely and effectively according to state guidelines. Please understatnd that the supply of the vaccine is limited.

Upon receiving your initial COVID vaccine, an appointment will be scheduled to administer the second dose of the vaccine. The recommended timeline for receiving the second dose is 28 days. Expect your appointments to last between 20-30 minutes.

We appreciate your flexibility and cooperation.
Full Name*
Date of Birth*

MonthDayYear
Phone Number (Daytime)*

Area CodePhone Number
Phone Number (Evening)*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email*
example@example.com
Job Title
Employer
Insurance Company
Insurance ID
Do you have any chronic health conditions?
Please indicate all health issues that are considered within the risk group.
Please list your current medication(s).
Do you have any allergies to medications or adverse reactions to vaccines?*

YesNo
If yes, please list.
Have you ever tested positive for COVID-19 in the past 90 days??

YesNo
If yes, please provide further details (date of diagnosis, were you hospitalized or not, treatment, etc.)
Are you currently experiencing any of the following COVID-19 symptoms? Check all that apply.

Loss of taste or smellDifficulty in breathingRunny noseCoughHigh feverBody achesNasal congestionDiarrheaPersistent pain or pressure in chestSore throat
I hereby declare that all the given information are accurate.*

I agree.
COVID Vaccination Appointment
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BrickStreet Vaccine Registration & Scheduler