Wait List for Your First COVID Vaccine
Thank you for trusting NET Health with your health!

PLEASE READ ALL INFORMATION BEFORE YOU COMPLETE THIS FORM.

1. Please complete the form below only once. Multiple entries may delay your appointment.

We encourage to you enroll people within your household on the same day that you register, so that we can work to schedule all eligible persons within your household on the same day.


2. Please provide a working cell phone and email address you check often.

It is important that you provide a working cell phone number and an active email address that you check on a regular basis, so that we are able to contact you and schedule you within the next available vaccination clinics.

If you share an email address and/or cell phone number with someone who is also currently eligible to receive the COVID vaccine, we will work to have you scheduled to come to our vaccine clinic on the same day.


3. Bring your health insurance information if you have it.

Receiving the COVID vaccine is free; however, there are costs associated with providing this service to the community, including supplies and staffing, that are being absorbed by NET Health.

The NET Health Immunizations Department asks that you bring proof of health insurance on the day that you return for your 2nd appointment, so that we can bill your health insurance provider to help us cover these administrative costs of providing the Moderna vaccine to you free of charge.


4. NET Health will schedule you when we have received sufficient supply of the COVID-19 vaccine to be able to provide second doses.


5. Completion of the form below does not schedule you for an appointment.

After you fully complete the form below, WAIT to receive an automated email from NET Health that will be sent to you by "SignUp Genius" that will display the next available days and times for you to select an appointment at our vaccine clinic.

When you receive that email, you may THEN sign up for your first dose of the COVID vaccine.


6. NET Health does not have connections with waiting lists being maintained by any other vaccine provider.


PLEASE COMPLETE THE ENTIRE FORM BEFORE YOU CLICK THE "SUBMIT" BUTTON.
First Name *
Only enter the person's first name
Middle Name (optional)
Only enter the person's first name
Last Name *
Only enter the person's last name
What is your current age (in years)?
Do you have any pre-existing health conditions that qualify you as Tier 1B eligible to receive the COVID vaccine? If "Yes", please describe.
Do you work in a job that qualifies you as Tier 1A eligible to receive the COVID vaccine? If "Yes", please be descriptive and be prepared to provide evidence when you arrive for your appointment
City of Residence
In what city do you live?
Zip Code
5-digit zip code
Please enter your email address.
What is your preferred email address for us contact you?
Please enter a cell phone number
We need to be able to contact you to schedule a future appointment.
Submit
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