COVID-19 Vaccine Pre-Registration For Individuals 75 And Older

Currently New York State is in Phase 1A of the COVID-19 Vaccine Distribution Program. This is a pre-registration form for individuals who may qualify for a COVID-19 vaccine in Phase 1B of the distribution program, under this specific designation ONLY:

People 75 and older

First Name

Last Name

Phone Number

Zip Code

Date of BIrth

Attestation

Questions	I AGREE
I UNDERSTAND THAT THIS IS A PRE-REGISTRATION FORM, AND THE INDIVIDUAL WHOSE INFORMATION WAS SUBMITTED IN THIS FORM WILL NOT BE ABLE TO REQUEST A COVID-19 VACCINE UNTIL DEEMED ELIGIBLE UNDER NYS DOH AND CDC GUIDANCE.	I AGREE
I ATTEST THAT THE INDIVIDUAL WHOSE INFORMATION WAS SUBMITTED IN THIS FORM IS 75 YEARS OF AGE OR OLDER.	I AGREE

COVID-19 Vaccine Pre-Registration For Individuals 75 And Older

Contact

COVID19 Vaccine Program