COVID-19 vaccine form info

COVID-19 vaccine form info

Our online form is easy to fill out and requires little information.  Due to high demand of COVID-19 vaccines and limited supply, it is important to have the following information available prior to filling out the form in order to complete the form in a timely manner.

Please have the following information ready for when you attempt to sign up.  The information pertains to the person to be vaccinated.

First and last name

Phone number

Email Address, if you do not have an email address use  Please note, using your own email address is the only way to receive a confirmation email.

Date of birth


Biological sex



Have they had COVID-19 in the past 14 days?

Have they had covid symptoms in the past 14 days?

Have you received a vaccine in the past 14 days? (e.g. – Influenza Vaccine)

Have you had convalescent antibody for COVID-19 treatment in the past 14 days?