COVID-19 Vaccine Waitlist

This form is for consumers who are interested in receiving the COVID-19 vaccine. Our pharmacies only have limited supply at select locations. The pharmacy will reach out to you if and when vaccine is available. Adding your name to this list does not guarantee you for vaccination through a Genoa Healthcare pharmacy.

First Name*

Last Name*

City*

State*

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Pharmacy Location*

Select your preferred Genoa Healthcare location

Select

AZ Pharmacy Location*

Select your preferred Genoa Healthcare location

Select

FL Pharmacy Location*

Select your preferred Genoa Healthcare location

Select

GA Pharmacy Location*

Select your preferred Genoa Healthcare location

Select

IL Pharmacy Location*

Select your preferred Genoa Healthcare location

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IN Pharmacy Location*

Select your preferred Genoa Healthcare location

Select

MI Pharmacy Location*

Select your preferred Genoa Healthcare location

Select

MN Pharmacy Location*

Select

MO Pharmacy Location*

Select your preferred Genoa Healthcare location

Select

OH Pharmacy Location*

Select your preferred Genoa Healthcare location

Select

PA Pharmacy Location*

Select your preferred Genoa Healthcare location

Select

TX Pharmacy Location*

Select your preferred Genoa Healthcare location

Select

VA Pharmacy Location*

Select your preferred Genoa Healthcare location

Select

WA Pharmacy Location*

Select your preferred Genoa Healthcare location

Select

Email Address

Phone Number*

Age*

Have you already received one dose of a multi-dose series COVID vaccine?*

Yes

No

Are you a healthcare worker?*

Yes

No

Are you considered an essential worker in your state?*

Yes

No

Do you currently use a health care clinic that has a Genoa Healthcare pharmacy on site?*

Yes

No

Do you currently use Genoa Healthcare pharmacy services?*

Yes

No

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