COVID-19 Vaccine Interest Form
This form doesn't guarantee that you will receive a vaccine from our pharmacy. This form will be used in the case of if someone cancels their COVID-19 vaccine appointment. Please use the COVID-19 Vaccine Sign Up form found on our website to create an appointment based on availability. The vaccine will be provided at ZERO cost to the patient, but we require government issued photo identification (for uninsured and insured), and insurance card (for insured).
Name of Vaccine Recipient (
Address of Vaccine Recipient
Street Address Line 2
State / Province
Postal / Zip Code
Date of Birth of Vaccine Recipient
Please enter a valid phone number.
Which of the following category of Phase 1A do you fall into?
Long-term care facility resident
Health care personnel
Age 65 or older
Age 18-64 with High-Risk Conditions such as cancer, chronic kidney disease, COPD, down syndrome, heart conditions, immunocompromised, obese, pregnant, sickle cell diseases, smoking and type 2 diabetes mellitus
If you selected Age 18-64 with High Risk Conditions; please be aware that Rios Pharmacy will need documentation from your primary or other type of doctor stating you have a high risk condition that qualifies for the COVID-19 Vaccine.
Are you a current patient of Rios Pharmacy?
Not yet, but I am interested in transferring!
This form doesn't guarantee that you will receive a vaccine from our pharmacy. You will receive and email and/or phone call and/or texts to notify you when your are eligible to book your vaccine appointment as soon as we confirm availability. The vaccine will be provided at ZERO cost to the patient, but we require government issued photo identification (for uninsured and insured), and insurance card (for insured).Please fill out one person per person in the family/group. *
Information collected here will not be shared with anyone. But please acknowledge below that you consent to Rios Pharmacy communicating with you via phone calls, text or email
Should be Empty: