COVID-19 Vaccine Appointment Request

Currently Schenectady County Public Health Services is offering appointments for Phase 1A vaccination ONLY.
Information about Phase 1A from the NYS Department of Health.

First Name

Last Name

Phone Number

Zip Code

Date of Birth

Attestation

Questions	I Agree
I BELIEVE THAT I FALL UNDER PHASE 1A UNDER NEW YORK STATE'S PHASED DISTRIBUTION GUIDELINES.	I Agree
I DO NOT FALL UNDER PHASE 1B	I Agree
I UNDERSTAND THAT FILLING OUT THIS FORM DOES NOT GUARANTEE THAT I AM ELIGIBLE TO RECEIVE A COVID-19 VACCINE AT THIS TIME, NOR DOES IT GUARANTEE I WILL RECEIVE A VACCINATION APPOINTMENT EVEN THOUGH I MAY BE ELIGIBLE TO RECEIVE ONE.	I Agree