COVID-19 Vaccination Notification Form
Please fill out your information below if you have interest in receiving a COVID-19 Vaccine at Moose Pharmacy. When we have more vaccines available, we will call individuals on this list so they can make an appointment online at
www.moosepharmacy.com
. Signing up does not guarantee an appointment. You will still need to book online on our website. THIS IS NOT AN APPOINTMENT.
* Required
First Name
*
Your answer
Last Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Phone Number
*
Your answer
Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
Which location would you be willing to receive your vaccine?
Concord
Locust
Kannapolis
Mount Holly
Mount Pleasant
Monroe
Salisbury
Which Vaccine are you interested in Receiving?
*
Moderna
Pfizier-BioNTech
Johnson and Johnson/Janssen
Any Available Vaccine
Required
Which vaccine group best describes you?
*
I am 65 years of age and older
I am a healthcare provider or volunteer
I work in Child Care or Pre-K to Grade 12 Schools
I am a frontline worker
I am between the age of 16-64 and have a high-risk health condition
Other:
Required
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