Brownstone COVID 19 Vaccination Request Form
Thank you for your interest in receiving a COVID-19 vaccine (Moderna).

 We are scheduling appointments in the order in which we receive the completed requests. Please be patient. We will contact you as soon as an appointment is available.

At this time, everyone eligible for vaccination according to the Alabama Department of Public Health Guidelines can request their vaccination appointment by completing the form below.  

Those eligible at this time include those people age 55 and older, people with intellectual and developmental disabilities, and people ages 18 to 64 with high-risk medical conditions, which include but are not limited to the following conditions:

Cancer
Chronic kidney disease
COPD
Heart conditions such as heart failure, coronary artery disease and cardiomyopathy
People with compromised immune systems
Solid organ transplant
Obesity (BMI greater than 30)
Pregnancy
Sickle cell disease
Smoking
Type 1 or 2 diabetes
Other medical conditions as determined by your medical provider

Also, critical workers in the following areas are eligible:
First responders
Corrections officers
Food and agriculture workers
U.S. Postal Service workers
Manufacturing workers
Grocery store workers
Public transit workers
People who work in the education sector
Childcare workers
Judiciary
People who work or live in congregate settings including but not limited to homeless shelters and group homes
Clergy/minister
State of Alabama continuity of Government strategy (state legislators, Supreme Court and appellate judges, constitutional officers, and cabinet agency heads).
Waste and wastewater
Food service (includes restaurant staff)
Shelter and housing (construction)
Finance (bank tellers)
IT and communication
Energy
Legal
Media
Public safety (engineers)

** You will get an email from brownstonehealthcare@gmail.com with your appointment time and further instructions**
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What Number Dose are you requesting? *
COVID 19: Have you tested positive for the virus in the last 90 days? *
COVID19: Have you received shot #1 at another location? *
Demographics: Name ( First & Last) *
Date of Birth: *
MM
/
DD
/
YYYY
Gender: *
Are you a current patient of Brownstone? *
Address: *
Phone Number *
Reason for Appointment: *
Medical History: Have you ever been diagnosed with any of the following: *
Required
Have you ever had an allergic reaction to a vaccine? *
Name of Employer: *
Patient Insurance: Name of Company
Policy Number
Is the Patient the Policy Holder: *
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