SEMC COVID-19 Vaccine List

Sleepy Eye Medical Center is currently collecting information for patients who are 12+ years of age or older and interested in receiving the COVID-19 vaccine. We will use information collected in this form to contact individuals to receive their COVID-19 vaccine when doses become available. Once this form is completed, please refrain from contacting us. We will contact you to schedule your appointment. Filling out this form does not guarantee you will receive an appointment through SEMC. We encourage you to seek out all avenues currently available in order for you to receive your vaccine. Sleepy Eye Medical Center has received Pfizer, Moderna and Johnson & Johnson vaccines. Pfizer and Moderna are two-dose series vaccines. Pfizer is given 21 days apart and Moderna is given 28 days apart. Pfizer is an option for individuals who are *12+ years of age. (*Parental/guardian consent is required for 12-17 year olds.) Johnson & Johnson is a single-dose vaccine. Please select your preference in the form below.

Patient Legal Name*
First Last
Name of Parent/Guardian
First Last
*For individuals who are12-17 years of age
Date of Birth*

00/00/0000
Vaccine Preference*
- Select All
- MODERNA (two-dose vaccine, given 28 days apart; option for 18+ years)
- PFIZER (two-dose vaccine, given 21 days apart; option for 12+ years)
- JOHNSON & JOHNSON (single-dose; option for 18+ years)
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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