COVID-19 Vaccine Card Replacement Request Form

COVID-19 Vaccine Card Replacement Request Form

Request a replacement card if you received your vaccine from 5 Minute Pharmacy. If you received your vaccine somewhere else, please request directly from your vaccine provider.
Contact Information
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Email *
example@example.com
Phone Number *
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Comments/Additional Instructions for Pharmacy
Please note due to high demand it will take up to 5 business days to fulfill your request.

You will receive a text and/or email when your card is ready for pick up at our pharmacy location at 94-216 Farrington Hwy #102 in Waipahu (next to Nanding's Bakery).

Do not submit a request more than once as it will not shorten the wait time. A photo ID is required for pick up.
Should be Empty:

Contact Information