COVID Vaccine Interest Form
Galileo Medical is thrilled to be bringing COVID vaccine directly to you in your community. For planning purposes, please fill out this brief form to share some details around your interest.

Call or text us 24/7 with questions or concerns.

North Carolina: 252-507-0588
New York: 347-933-6246
What is your name? *
What is your date of birth? *
MM
/
DD
/
YYYY
What is your phone number? *
What is your zipcode? (We ask so we can come directly to your community)
When are you available to get the vaccine?
Weds, April 14th
Thurs, April 15th
Fri, April 16th
Sat, April 17th
The following week
8-10am
10am-12pm
12pm-2pm
2pm-4pm
4-6pm
6-8pm
How far are you willing to travel to get the vaccine?
Clear selection
Are you currently a patient with Galileo Medical?
Clear selection
Have you had any of the following?
Submit
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