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Kennesaw Pharmacy Covid -19 Waiting List
Please fill this form out to have our Pharmacy team reach you to schedule appointment as vaccine and appointment become available
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* Indicates required question
Email
*
Your email
We Currently only able to get Moderna COVID-19 Vaccine ONLY!
What is your Full Name?
*
Your answer
Is this your First Covid-19 Shot?
*
Yes
No
If NO to above please provide the BRAND and the DATE you got the shot ? if Yes write N/A
Your answer
What is your Phone Number ? (Provide easiest to reach you)
*
Your answer
What is your e-mail address?
*
Your answer
What is your Age?
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Your answer
Please list any health conditions you have?
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Your answer
Which County you live in?
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Cobb
Fulton
Cherokee
Dekalb
Paulding
Other:
Required
What is your Zip Code?
*
Your answer
What insurance you have insurance?
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Medicare
Private Insurance (including Obamacare)
Medicaid
Uninsured
Do you wish to Register any one else like spouse, family member, or others?
*
Yes
NO
Any other information you would like to share with Pharmacy Staff? Such as health condition
Your answer
What is their Full Name and Age?
Your answer
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