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.
Street Address Line 2
State / Province
Postal / Zip Code
What is your age:
Email address. Please provide an email that is regularly monitored. You will be receiving registration information and appointment reminders
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?
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:
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
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
High blood pressure
Should be Empty: