Second Dose Waitlist (Received First Dose Elsewhere)

2nd Dose COVID-19 Vaccine Waitlist

For people who DID NOT get their 1st vaccine dose at Aviva Pharmacy
This waitlist is for people who DID NOT receive their 1st dose at Aviva Rx and received it at another location.

If you received your 1st dose at Aviva Pharmacy, we will contact your with your 2nd dose appointment, so DO NOT fill out this form.
Did you receive your 1st vaccine dose at Aviva Pharmacy?

Yes No

Registration Form
Patient Name *

First Name Last Name
Patient Date of Birth *

Month Day Year
Date
Cell Phone *
Please enter a valid phone number.
Patient Email Address *
Double Check You Got This Correct!
Date of 1st Dose *

Month Day Year
Date
Location of 1st Dose *

This list is for ONLY for people who did not receive their 1st dose at Aviva Rx.

If you received your 1st dose at Aviva Pharmacy, we will contact you directly regarding your 2nd dose appointment.

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