COVID-19 Vaccine Booster Waitlist

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If you are in need of a COVID-19 Vaccine Booster, please fill out the form below! Once we recieve our shipment of boosters, our staff will be reaching out to you to schedule your appointment. Please fill out a seperate form for each person you are registering.

Have you (Check all that apply) *

Been receiving active cancer treatment for tumors or cancers of the blood

Received an organ transplant and are taking medicine to suppress the immune system

Received a stem cell transplant within the last 2 years or are taking medicine to suppress the immune system

Been diagnosed with moderate or severe primary immunodeficiency (such as DiGeorge syndrome, Wiskott-Aldrich syndrome)

Been diagnosed with advanced or untreated HIV infection

Been receiving active treatment with high-dose corticosteroids or other drugs that may suppress your immune response

NONE OF THE ABOVE

Required

First Name *

Last Name *

Date of Birth *

YYYY

Phone Number *

Phone Number Type *

Home

Cell

Work

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