Covid-19 Vaccination Registration

First Name

Last Name

Date of Birth:

Phone Number

Email Address

Confirm Email Address

1. Do you meet the State’s current criteria for vaccine eligibility?

yes no

2. Have you been diagnosed with COVID-19 in the past 90 days?

yes no

3. Have you received another COVID-19 vaccine or any other vaccine in the past 14 days?

yes no

Select Appointment Date and Time: