Pharmacy COVID-19 Vaccine Waitlist Form

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 about COVID-19 vaccine when it is available at our pharmacy. We appreciate your patience.
If you have questions about which category you fall in, please visit these links to help you decide.

Healthcare Worker: https://covid19.ncdhhs.gov/vaccines/find-your-spot-take-your-shot/deeper-dive-group-1

Essential Worker: https://covid19.ncdhhs.gov/vaccines/find-your-spot-take-your-shot/deeper-dive-group-3

16-64 with Chronic Health Condition: https://covid19.ncdhhs.gov/vaccines/find-your-spot-take-your-shot/deeper-dive-group-4

If you are interested to see what group you fall in, visit here: https://findmygroup.nc.gov/
The Category You Fall In *
Primary Medical Insurance *
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Email
example@example.com
Phone Number *
Please enter a valid phone number.
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Race *
Ethnicity *
Gender *
Are you a member of a state or federal recognized tribal nation? *
If available, I prefer: *

Pfizer/Moderna (2 shots, more effective) Johnson & Johnson (1 shot, less effective; also not expected in stores for a few more weeks)
If you answered Johnson & Johnson, would you also take Pfizer/Moderna if Johnson & Johnson is not available?

Yes No
If available, what day would be best for your appointment? *

Monday Tuesday Wednesday Thursday Friday
Should be Empty:

Get on the COVID-19 Vaccine Waitlist!