COVID-19 Vaccine Sign Up

Please submit the information below to join our COVID-19 vaccine waitlist, we will contact you to schedule an appointment. We are currently administering the Moderna vaccine and are excited to be part of the vaccination effort!

Name

First Name

Last Name

Email

Phone

(###)

###

####

Are you a current Wilson Pharmacy patient?

Yes

No

Have you already received two doses of COVID vaccine?

Yes

No

If yes, when did you receive your 2nd dose?

MM

DD

YYYY

Message