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Interest Form for Senior Center Vaccine Clinics - May 2021

  1. covidvaccine2_336537767

  2. Interest Form for City of Bowie Vaccine Clinic

    Clinic location: Bowie Senior Center, 14900 Health Center Drive, Bowie. This clinic is a partnership between the City of Bowie and Safeway Pharmacy. Any person, age 12+ is eligible to be vaccinated at this site. More info about the clinic at www.cityofbowie.org/vax. After completing the form below you will be pre-registered to be vaccinated at our clinic. You will receive a call, usually within 24 hours, to schedule your appointment.

  3. Please provide the following information on your COVID vaccine preference

    Only Pfizer vaccines are being provided at this time.

  4. Preferred date*

  5. Are you requesting a first or second dose appointment?

    We are now accepting requests for second dose appointments, even your first Pfizer appointment was administered elsewhere.

  6. Please provide the following information for the person who will be receiving the COVID vaccine.

  7. Are you over the age of 50?

  8. Biological Sex*

  9. Do you have any medical conditions that may cause you to have severe complications from COVID-19?*

  10. Do you have a physical or mental disability that may cause you to have severe complications from COVID-19?*

  11. Please enter additional contact information below to receive appointment reminders and confirmations.

  12. By providing my telephone number, I agree to receive recurring automated or prerecorded marketing and transactional phone calls and text messages (including related to COVID vaccines and testing) from or on behalf of Albertsons Companies Inc. and its affiliates to the phone number provided. Consent is not a condition of purchase. Reply STOP to STOP, HELP for HELP, message and data rates may apply.

  13. Please review and acknowledge by entering your name

  14. Are there other people in your household you would like to register as well?

    If there are other people in your household you would like to pre-register, please state how many additional people (besides yourself) you would like to pre-register. You will be asked to fill in the name, date of birth, and biological sex of each additional person you are pre-registering.

  15. Biological Sex for Additional Person #1

  16. Biological Sex for Additional Person #2

  17. Biological Sex for Additional Person #3

  18. Biological Sex for Additional Person #4

  19. Leave This Blank: