Covid-19 Vaccine Appointment Form – Part 1


    Qualifications:

    You must have one of the following to qualify to receive the Covid-19 vaccine at this time.

  • - You must be NYS resident
  • - 18 and above


  • YesNo

    YesNo

    YesNo

    YesNo
    You are not currently eligible at time.

    Please check back at a later date.


    Patient Information

    MaleFemale



    *Please only click the button 1 time.




    REMINDER:

    • PLEASE WASH YOUR HANDS AND USE HAND SANITIZER
    • PLEASE DO NOT SHAKE HANDS, TOUCH OR HUG DURING YOUR VISIT
    • WEAR MASK AT ALL TIMES!!!