SEMC COVID-19 Vaccine List

If you are interested in scheduling a COVID-19 vaccine dose for you or your child, please complete the below form. Once you complete our form, please refrain from contacting us. We will use this information to contact you for scheduling. Staying up to date on your COVID-19 vaccines is important for your health and protecting others around you, especially from serious disease, hospitalization, and death. To stay on track with vaccinations and learn more about the COVID-19 vaccine, please visit: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html. *NOTE: This site also identifies which COVID-19 vaccine(s), doses and/or boosters are appropriate for you and your child.

Patient Legal Name*
First Last
Name of Parent/Guardian
First Last
*For individuals who are 5-17 years of age
Date of Birth*

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Vaccine Preference*
- Select All
- MODERNA (two-dose vaccine, given 28 days apart; option for 18+ years)
- MODERNA BOOSTER (must be 5+ months out from second Moderna vaccine)
- PFIZER (two-dose vaccine, given 21 days apart; option for 5+ years)
- PFIZER BOOSTER (must be 5+ months out from second Pfizer vaccine)
- JOHNSON & JOHNSON (single-dose; option for 18+ years. *NOTE: SEMC will not administer J&J boosters. Please contact local Public Health, if interested.)
- PFIZER SECOND BOOSTER (adults 50 years and older and/or immunocompromised - at least 4 months after first booster)
- MODERNA SECOND BOOSTER (adults 50 years and older and/or immunocompromised - at least 4 months after first booster)
Please select how you qualify:*
- Age 18 or older
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number*
Email
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SEMC COVID-19 Vaccine List

SEMC COVID-19 Vaccine List

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