Monroe County, NY COVID-19 Vaccine Registration Form

Greece Community & Senior Center
This link is for all vaccine eligible individuals who live in New York State. The two-dose, Pfizer vaccine will be administered.

* Required Fields

Confirmation of appointment will be sent to this email.
Available date/time Unavailable Selected

Recipient

Eligibility Group
Bring proof of eligibility with you to appointment!
Insurance Information
The COVID-19 vaccine is available at no cost to you. Insurance information is collected for administrative purposes. Bring your insurance card with you to appointment!
Enter name of primary subscriber if relationship is not "self" of if name on card differs from recipient name entered above.
Enter address of primary subscriber if different than the recipient address entered above.
Emergency Contact (optional)
Primary Care Provider (optional)
Screening Questions
Antibody therapy and convalescent plasma for COVID-19 is a medical treatment provided to some people with COVID-19 infection.
This allergy does not apply to mild allergic reactions such as rash only and does not include allergies that are not related to a vaccine (for example it does not include allergies to: pets, venom, environmental, latex or oral medications).
This includes tetanus, hepatitis A, mumps, flu or any other vaccine.
YOU WILL NOT BE ABLE TO EDIT THIS INFORMATION AFTER CLICKING THE SUBMIT BUTTON BELOW. PLEASE MAKE SURE ALL INFORMATION IS CORRECT.