Kemper Drug COVID-19 Vaccine Interest Form
At this time we have the Moderna two dose vaccine and are vaccinating anyone over the age of 18. We are currently caught up on our wait list, so you should receive an email from us within 24 hours of submitting this interest form. The email will include instructions and a link to click on to access the schedule. Please check your junk/spam/promotions folders, etc. if you do not hear from us. If you have questions or concerns, please call or text us at 763-441-1353. We are very excited to help support our community with this process. Thank you for supporting us with your patronage!
Name
*
First Name
Last Name
Birth Date
*
-
Month
-
Day
Year
Date
Email. Enter your address in each box to ensure accuracy. Both entries must match each other
*
Confirmation 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
Do you currently fill your prescriptions at the pharmacy at Kemper Drug?
Yes
No
Submit
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