Full Name
*
Phone
*
Email
*
Which dose of COVID vaccine do you need?
*
1st Dose
2nd Dose
3rd Dose
Are you 65 years of age or older?
*
Yes
No
Are you 18 or older?
Yes
No
Are you a front line essential healthcare worker in education or childcare?
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Yes
No
Are You A Front-line Essential Worker (Group 3) And Work In-person At Least One Day A Week in any of these Categories? (Education & Child Care, Critical Manufacturing, Essential Goods, Food & Agriculture, Government & Community Services, Public Health, Public Safety, Transportation)
Yes
No
(Group 4) Are you an adult 16-64 of age with a high risk medical condition (including current or past smoking) or living in congregate settings?
Yes
No
Are you a front-line essential worker (Group 4) and work in-person at least one day a week on one of these categories? (Chemical, Commercial facilities, Communications and information technology, Defense industrial base, Energy, Financial services, Hazardous materials, Hygiene products and services, Public works and infrastructure support services, Residential facilities, housing, and real estate, Water and wastewater)
Yes
No
Did you answer no to all the previous questions?
Yes
No
Are you a current Josefs or Main St. Pharmacy patient?
*
Yes
No
Please confirm you understand your vaccine location will be at Josefs Raleigh Location.
Josefs Pharmacy Raleigh at 2100 New Bern Ave Raleigh, NC
Based on the CDC requirements for a 3rd dose, do you qualify to receive it?
Yes
No