Initial COVID-19 Vaccine Interest Form
We do NOT have COVID-19 vaccine yet, but we anticipate receiving some vaccine soon. We have not been provided an anticipated date for being able to vaccinate the public. Staff cannot provide additional information or register you over the phone or in store.
Please provide your best phone number and e-mail address. We will contact you when & if vaccine becomes available.
Street Address Line 2
State / Province
Postal / Zip Code
Check the conditions that apply to you:
Chronic Kidney Disease
Chronic Lung Disease (Asthma, COPD, etc)
Overweight / Obese
Are you currently taking any medication?
Do you have any medication allergies?
What is your gender?
Other / Prefer not to say
Prefer Not to Say
Race/Ethnicity (for reporting to Virginia Department of Health)
American Indian or Alaskan Native
Black or African American
Hispanic or Latino
Native Hawaiian or Pacific Islander
Do you use or do you have history of using tobacco?
Type of Pharmacy Insurance
Insurance Member ID Number
Should be Empty: