Covid-19 Vaccine Interest Form
*At this time we are only able to vaccinate Georgia residents.*

Please fill out the following form if you would like to be contacted by Compounding Solutions Pharmacy and Wellness when you are eligible to schedule vaccine administration. By completing this form, you are not registering or obligated to receive the COVID-19 vaccine from us. We will contact you when the vaccine is available for your phase. Due to a large amount of interest, it may be some time before you might be vaccinated. We are working as quickly as we can to get everyone vaccinated. Thank you for your patience! If you would like to learn more about the vaccine go to https://www.fda.gov/media/144638/download .
Are you interested in the vaccine for yourself or are you inquiring about having a vaccine clinic at your workspace? *
First Name *
Last Name *
Phone Number *
Email Address *
Do you identify with any of the following categories? (check all that apply) *
Required
If you are a caregiver for a child with complex conditions, then what condition does your child have?
Clear selection
If you are a teacher, educator, or school staff, what school do you work for?
Are you inquiring about your 1st or 2nd dose? If you received your 1st dose from us, please don't fill out this form for your 2nd dose. *
If inquiring about 2nd dose, which vaccine did you get for your 1st dose?
Clear selection
What date are you eligible to receive your 2nd dose?
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