Aitkin GuidePoint Pharmacy COVID-19 Vaccine Wait List

Aitkin GuidePoint Pharmacy COVID-19 Vaccine Wait List

At this time we are vaccinating those over 65, those over 45 that have a medical condition, immunocompromised patients such as those with active cancer, and those that are caregivers. Please only fill out if you are in those categories. Look to allocation of vaccine to 1b priority two and three from the mdh. You will be contacted as vaccine becomes available so please do not contact the pharmacy in regard to the status. If you are able to get vaccine elsewhere that is great but, if you would please, come redo this form saying take me off your list. We are very excited to be able to be a part of this process! Thank You!
Name*

First NameLast Name
Medicare Number
Take Me off your list.

Please take me off your list as I have got my vaccine elsewhere
Birth Date*

MonthDayYear
Date
Gender*

FemaleMale
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company
Insurance ID
***There is no charge for any patient receive to the COVID-19 vaccine. We bill insurance for the administration of the vaccine to assist with the cost of staffing. Regardless of insurance coverage, you will not be charged.***

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