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.
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)