Queens Health Systems Vaccination Clinic @ Kapolei Shopping Center 11/7 Sunday (11am-4pm) 11/28 Sunday (11am-4pm)
Please print and complete registration form, consent form (if under 18 years old), and pre-screening forms. Hard copies will also be available.

Registration Form:
Consent Form (if under 18, parent signature is required):
COVID-19 Vaccine Pre-screening Form:

Booster and 3rd doses attestation form:
*Booster: 180 day minimum between 2nd dose and booster; Pfizer only.
Signature required on attestation form please.
*3rd dose: Immunocompromised individuals only, 28 day minimum between 2nd and 3rd dose.
Moderna and Pfizer only.
Signature required on attestation form please.

Fact sheets:
Pfizer: https://bit.ly/3BC36ka
EUA Fact Sheets:
Janssen: https://bit.ly/3CObHS7
Moderna: https://bit.ly/37QsWnE
Sign in to Google to save your progress. Learn more
Date of Attendance *
Type of vaccine choice: *
Last Name, First Name *
Address *
Age *
Date of Birth *
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy