COVID-19 Vaccine Pre-Registration

Date of Birth

First Name

Last Name

Phone

Email

Please check off any chronic medical conditions that apply to you:

Chronic Kidney Disease

Cancer

COPD

Down Syndrome

Heart Condition

Solid Organ Transplant

Obesity (BMI > 30)

Pregnancy

Sickle Cell Disease

Smoking

Type II Diabetes

My phone can receive text messages

Would you be availble within 60 minutes if we have a cancellation?

No

Yes

Please check off all days you would be available to come in.

Monday

Tuesday

Wednesday

Thursday

Friday

Thanks for submitting!

6 Spruce Street

Sanford, ME 04073