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
. Signing up does not guarantee an appointment. You will still need to book online on our website. THIS IS NOT AN APPOINTMENT.
Date of Birth
Which location would you be willing to receive your vaccine?
Which Vaccine are you interested in Receiving?
Johnson and Johnson/Janssen
Any Available Vaccine
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
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