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
Email address *
First Name *
Last Name *
Date of Birth *
Age *
Home Address *
City/Town *
Phone number (Cell Phone Preferred) *
Sex *
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. *
A copy of your responses will be emailed to the address you provided.
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