Spanish (Latin America)
COVID-19 Vaccine Registration Form
The pharmacy will contact you to schedule an appointment once you are eligible to receive the vaccine. The pharmacy will prioritize appointments based on the Washington Phases for COVID vaccine. If you register before you are eligible, you will be put on a waitlist and will be called to schedule an appointment once you reach eligibility in the order registrations are received.
Are you able to schedule an appointment with short notice?
Yes, I can be there in 10 minutes- 1 hour
Yes, I can be there within a few hours
Yes, I can usually be available the same day
No, I am not able to schedule on short notice
I prefer not to say
Let me type:
Please enter a valid phone number.
Street Address Line 2
State / Province
Postal / Zip Code
*Insurance is NOT required to get your vaccine. Please put NA if you do not have prescription insurance.
Insurance Rx BIN, Group, PCN
If you do not know this information, please bring your prescription insurance card to your appointment.
Are you eligible for Medicare?
Yes. My Medicare B number is:
Health & Employment
Please list your allergies
Have you ever experienced a severe allergic reaction (anaphylaxis)? If so, please tell us what happened.
I hereby declare that all the given information is accurate. I understand that I will be contacted using the contact information I provided to schedule my appointment once I am eligible for the vaccine and the pharmacy has vaccine in stock. If the pharmacy is unable to reach me, an appointment will not be scheduled.
I agree with the statement above
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