Contact Information
This form is to be completed by Braintree residents aged 65 and over who want to be placed on the waiting list to receive the COVID-19 vaccine. Please direct any inquiries to the Braintree Health Department at 781-794-8099 or by email at
covidvaccine@braintreema.gov
.
* Required
Email address
*
Your email
First Name
*
Your answer
Last Name
*
Your answer
Date of Birth
*
Your answer
Age
*
Your answer
Home Address
*
Your answer
City/Town
*
Braintree
Other:
Phone number (Cell Phone Preferred)
*
Your answer
Sex
*
Female
Male
Other:
Please be advised, the COVID-19 vaccine is two doses and you will need to receive the second dose 28 days after receiving the first dose.
*
Yes, I understand and will be available to receive the second dose 28 days after receiving my first dose.
A copy of your responses will be emailed to the address you provided.
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