I Want to Get A COVID-19 Booster!

Please complete this form if you would like to receive a COVID-19 booster vaccination. This places you on our list to receive the booster when it becomes available for you. Right now boosters are only available for individuals that received the PFIZER vaccine 6 or more months ago AND are over 18 years old with a qualifying condition or reason.

Last Name

First Name

Date of Birth

DD/MM/YYYY

mm/dd/yyyy

Current Phone Number

City and State

I previously received the following vaccine:

The date I last recieved a COVID vaccine was:

mm/dd/yyyy

Chronic Disease States Please check all of the following that apply to you.

greater than or equal to 65 years in age

resident of a long-term care setting

work at a job that puts me at high risk of COVID exposure

cancer

chronic kidney disease

chronic obstructive lung disease (COPD)

asthma (moderate to severe)

other chronic lung disease including interstitial lung disease, cystic fibrosis, or pulmonary hypertension

dementia or alzheimers

diabetes

down syndrome

high blood pressure

heart conditions including heart failure, coronary artery disease, cardiomyopathies

HIV infection

immunocompromised

liver disease

overweight or obese (BMI >25)

pregnant

sickle cell disease or thalassemia

smoker, current or former

solid organ or blood stem cell transplant

stroke or cerebrovascular disease

substance use disorder

other

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