Get on the COVID-19 Vaccine Waitlist!
Once you fill out this form, we will add you to the waitlist, and you will be contacted via email and/or SMS (text) about COVID-19 vaccine when it is available at our pharmacy. We appreciate your patience. As of March 7th, we are currently only receiving Johnson & Johnson vaccine. If you wish to receive a different COVID-19 vaccine, please reach out to another provider to see what vaccine they are administering.
Name
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your age:
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Please Select
age 18-30
age 31-40
age 41-50
age 51-64
age 65+
Email address. Please provide an email that is regularly monitored. You will be receiving registration information and appointment reminders
*
Confirmation Email
example@example.com
Phone Number
*
Please enter a valid phone number.
If the phone number you provided is a cell phone, would you like to also receive the vaccine registration link via SMS (text) message?
*
Please Select
Yes
No
N/A phone number provided is not a cell phone
We are currently vaccinating Phase 1b and 1c. Please select which category you fit in:
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National Guard
Grocery worker, Public transit workers or blood bank workers
Public safety answering points (911)
IT workers unable to work from home
Any other essential workers (per Cybersecurity & Infrastructure Security Agency) unable to work from home
Congregate setting residents and staff
age 18-64 with 1 or more underlying conditions
Age 65+
Childcare, preschool or K-12 school worker
I do not currently fit into Phase 1b or 1c. I would like to be kept on the waiting list for notice when the general public is eligible for vaccination.
Underlying Health Conditions. Select all that apply
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None
Cancer
Diabetes
COPD
Heart condition
Obesity
Smoking
Kidney Disease
High blood pressure
High cholesterol
Other
Submit
Should be Empty: