Date of Birth
W - White
B - Black
I - American Indian
A - Asian
P - Pacific Islander
O - Other
U - Unknown
Hispanic or Latino
Not Hispanic or Latino
Special Accommodations Needed (wheelchair access, translator, etc.)
Bring proof of eligibility with you to appointment!
Select the eligible vaccine priority group you belong to
* More Info
Eligible age at time of visit per current NYS guidelines
Under 30 years old & not eligible for any other priority group
Under 65 with underlying health condition
High-risk hospital and FQHC staff, including OMH psychiatric centers
Certified NYS EMS provider
Other Healthcare Worker
Staff of nursing home, skilled nursing facility, or adult care facility
Resident of nursing home, skilled nursing facility, or adult care facility
County Coroner or Medical Examiner (or employee or contractor of same) exposed to infectious material or bodily fluids
Funeral Worker exposed to infectious material or bodily fluids
Homeless Shelter Resident
First Responder or Support Staff for First Responder Agency
Outpatient/Ambulatory front-line, high-risk health care workers
P-12 Schools Personnel
In-Person College Faculty and Instructors
Group Childcare Provider, Employee, or Support Staff (in a Licensed, Registered, Approved, or Legally Exempt Group Child Care Provider/Setting)
Public Transit Personnel
Public Facing Grocery Store Workers
Homeless Shelter Worker
Home care worker/aide, hospice worker, personal care aides, or consumer-directed personal care worker
Other essential staff
Persons who are currently pregnant
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)
I have read the entire
list of priority groups for COVID-19 vaccination. I hereby certify that I am part of a priority group identified for COVID-19 vaccination, for the week that I am being vaccinated.
I further agree that by clicking "I AGREE" and submitting this form, I am placing the legal equivalent of my handwritten signature on such certification. *