Which brand booster do you want to receive?
Which brand vaccine did you receive for your initial series?
Enter the dates you previously received vaccine doses for your initial series. If you did not receive 2nd or 3rd doses (3rd only applies to immunocompromised), leave those dates blank.
Date of Birth
W - White
B - Black
I - American Indian
A - Asian
P - Pacific Islander
O - Other
U - Unknown
Hispanic or Latino
Not Hispanic or Latino
Special Accommodations Needed (wheelchair access, translator, etc.)
The COVID-19 vaccine is available at no cost to you. Insurance information is collected for administrative purposes.
Bring your insurance card with you to appointment!
Enter name of primary subscriber if relationship is not "self" of if name on card differs from recipient name entered above.
Enter address of primary subscriber if different than the recipient address entered above.
Emergency Contact (optional)
Primary Care Provider (optional)
I have read the entire
list of priority groups for COVID-19 vaccination. I hereby certify that I am part of a priority group identified for COVID-19 vaccination, for the week that I am being vaccinated.
I further agree that by clicking "I AGREE" and submitting this form, I am placing the legal equivalent of my handwritten signature on such certification. *
YOU WILL NOT BE ABLE TO EDIT THIS INFORMATION AFTER CLICKING THE SUBMIT BUTTON BELOW. PLEASE MAKE SURE ALL INFORMATION IS CORRECT.