Please fill out both of these forms:

BEFORE APPOINTMENT SCHEDULING:

• New York State Consent Form (printable)
  • This form is required by the state of New York to receive a COVID-19 vaccination.   Please sign up online and the pharmacy will be in touch to schedule an appointment.
  • Anyone who cannot answer ‘no’ to questions 1-4 should not come to the clinic and will be rescheduled.  Anyone who cannot answer ‘no’ to questions 5-11 should consult their own physician before registering for a vaccination.

AFTER YOU’VE BEEN SCHEDULED BUT BEFORE YOUR APPOINTMENT:

• New York State Self-Reporting Form
  • New York State Department of Health requests all individuals across New York State to self-report select demographic data such as occupation, race, and ethnicity prior to vaccine administration. This information is critically important for tracking vaccination progress throughout the State and ensuring appropriate vaccine distributions in all regions of the state.

Get The Facts About The Vaccine

• Pfizer
• Moderna