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 6 months to 17 years of age
Date of Birth*
00/00/0000
Vaccine Preference*
- Select All
- MODERNA (SEMC currently has this two-dose vaccine available for 18+)
- MODERNA BOOSTER (SEMC offers this for 18+; must be 5+ months out from primary series)
- MODERNA SECOND BOOSTER (adults 50 years and older and/or immunocompromised; at least 4 months after first booster)
- PFIZER (two-dose vaccine for 5+ years old; three-dose vaccine for 6 months to 4 years old)
- PFIZER BOOSTER (must be 5+years old and 5+ months out from second Pfizer vaccine)
- PFIZER SECOND BOOSTER (adults 50 years and older and/or immunocompromised - at least 4 months after first booster)
- BIVALENT BOOSTER (ages 5+; provides protection from omicron BA.4 and BA.5 variants)
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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