Select one: Mobile Land line 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your First Name and Last Name in the designated fields. Ensure that the names match your identification documents for accuracy.
3. Fill in your Date of Birth and Age. This information is crucial for verifying eligibility for vaccination.
4. Provide your Street Address, City, State, and Zip Code. Accurate address details help in confirming your identity and residency.
5. Select either Mobile or Land line by checking the appropriate box. This will indicate how you prefer to be contacted.
6. Complete the Drug Allergies section if applicable, followed by your Physician's details including their Phone Number and Address.
7. Answer the eligibility questions regarding COVID-19 exposure and symptoms honestly. Your responses will guide the pharmacist's assessment.
8. Fill out the Medicare/Insurance Information section accurately, ensuring all details match your insurance card to avoid payment issues.
9. Initial where indicated to confirm understanding of consent and privacy practices before signing at the bottom of the form.

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