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COVID Vaccine Interest

At this time demand for vaccines is exceeding supply. We will administer vaccines as we receive them. This form helps us prepare by allowing us to track interest and request sufficient allocations. Vaccines will be distributed as we receive them based on interest and public health eligibility. We will contact patients or their designated caregiver to schedule appointments.

Please have your Medicare Card (with your Medicare Number) and/or insurance card available.

COVID-19 VACCINE INTEREST FORM 1.21.21

  • Patient Info

  • XXX-XXX-XXXX
  • XXX-XXX-XXXX
  • Physician Info

  • Contact Info

    If you are a patient filling out this form and want to be contacted directly choose patient and leave fields below empty. If you are not the patient or want us to contact a caregiver/family member, fill out the fields below.
  • XXX-XXX-XXXX
  • We will contact you.

    We will distribute vaccines as we receive them based on public health eligibility and a priority assessment. We will contact patients or their designated caregiver to schedule appointments.
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