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Clinton Discount Pharmacy COVID-19 Vaccine Registration
Please fill out this form to have our team reach out to you to get your shot set up!
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Last name (as it appears on your driver's license or insurance card)
*
Your answer
First name (as it appears on your driver's license or insurance card)
*
Your answer
Your age
*
Your answer
Your phone number (best to reach you)
*
Your answer
email address
*
Your answer
Is this your 1st dose of COVID-19 vaccine
*
Yes
No
What insurance do you have, if any?
*
Medicare
Medicaid
Private insurance (including Marketplace or "Obamacare")
No insurance
Required
Have you ever been diagnosed with COVID-19?
Yes
No
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Which shot would you prefer?
Janssen (Johnson & Johnson) (one shot)
Moderna (2 shot series)
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