COVID-19 Vaccine Pre-registration- Facilities
DISCLAIMER: Filling out this form does not guarantee your chances of getting the COVID-19 vaccine. Once we have more information, we will contact you personally. Thank you for your interest and stay safe.
* Required
Email address
*
Your email
First and last name of Contact Representative
*
Your answer
Facility Name
*
Your answer
Facility Type (LTC, SNF, Group Home, etc.)
*
Your answer
Full Address of Facility
*
e.g. "1919 W North Ave, Milwaukee, WI 53206" "Homeless" if you are currently experiencing homelessness
Your answer
Phone Number
*
Full phone number with area code. e.g. 414-374-0000
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This form was created inside of hayatrx.com.
Report Abuse
Forms
