COVID-19 Vaccine Registration Form
PLEASE NOTE: FILLING OUT THIS FORM DOES NOT GUARANTEE YOU WILL RECEIVE A VACCINATION. WE WILL CONTACT YOU VIA EMAIL WHEN YOU ARE ELIGIBLE TO BOOK YOUR VACCINE APPOINTMENT.
Patient Physical Address
Street Address Line 2
Postal / Zip Code
Date of Birth
Gender at birth
Patient Phone Number
Emergency Contact Name
Relationship to Emergency Contact
Phone Number of Emergency Contact
Choose from the following. If you do not fall under any of these categories, you are not eligible for Phase 1A+ according to the GA State Department of Public Health. Please bring your proof of employment with you to your appointment.
LTC staff and residents
Adults 65+ and their caregivers
Law enforcement, fire fighters, first responders
Submit Registration Form (required)
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