VACCINATION REGISTRATION
After registration is completed, a RelyCare Pharmacy staff member will contact you when the vaccine is available to be administered to you. At that point, we will provide you with a link to schedule your vaccination appointment.
Today's Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Home Phone Number (Patient or Guardian)
Please enter a valid phone number.
Cell Phone Number (Patient or Guardian)
Please enter a valid phone number.
Email (Patient or Guardian)
*
Do you have a vaccine manufacturer preference?
Please Select
Moderna
Johnson & Johnson
No preference
Where are you wishing to receive the vaccination?
*
In-Store at RelyCare Pharmacy
Are you one of the following...
*
Long Term Care Resident
Long Term Care Staff
Neither
Choose one of the following...
Please Select
Vaccination In-Store at RelyCare Pharmacy
Vaccination in Parking Lot at RelyCare Pharmacy
Immobile Resident - Vaccination at Facility
Name of the Facility
Facility Contact Name
First Name
Last Name
Facility Contact Phone
Please enter a valid phone number.
Facility Contact Email
example@example.com
Race (optional)
White
African American
Hispanic
Native American
Middle Eastern
Asian
Other
Do you have any underlying health conditions?
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Submit
Should be Empty: