J&J Janssen COVID-19 Vaccine appointment
Vaccine you are scheduling for:
Johnson & Johnson's Janssen Covid-19 Vaccine
Are you 18 years of age or older
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YES
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Which dose you're booking for
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1st dose
2nd booster dose
Vaccine Recipient Name
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First Name
Middle Name
Last Name
Select an appointment time:
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Vaccine Recipient Physical Address "No PO Box"
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Street Address
Street Address Line 2
City
State Initials
Postal / Zip Code
Date of Birth
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Month
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Day
Year
Gender at birth
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Male
Female
Race
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American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Ethnicity
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Hispanic or Latino
Not Hispanic or Latino
Unknown
Drug/Food Allergies (If no allergies "type none" )
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Cell Phone
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Please enter a valid phone number.
Email
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example@example.com
Do you have health Insurance?
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YES
NO
What is your social security number (optional)
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