COVID-19 Vaccine Pre-Registration

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COVID-19 Vaccine Pre-Registration

Please Note: At this time, you can call the pharmacy to sign up for a vaccine appointment. However, if you would prefer, you can fill out this form to pre-register for the COVID-19 vaccine FIRST DOSES. Do not sign up for second doses, third doses or boosters on this list. We will get in touch with you as soon as possible to get you vaccinated. Thank you!

* Indicates required question

Name *

Your answer

Email *

Your answer

Phone number *

Your answer

Address *

Your answer

Date of Birth *

MM

/

DD

/

YYYY

Which pharmacy would you like to visit? *

Schuylkill Haven

Shenandoah

Hegins

Palmyra

Bel Air, MD

Joppa, MD

Any other comment or note you would like to make?

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