Bruce & Human Drug

Vaccination Appointment Request

Covid-19 Test/Vaccination Appointment Request

We will call you to schedule your appointment.
All fields with red asterisks are required.

Full Name of person receiving the Vaccination / Test.

Name

First

Last

Middle

Multiple Choice*

Male

Female

Other

If other, please explain.

Date of Birth*

day

month

year

Email*

Address*

Street Address City State / Province / Region Postal / Zip Code

Phone number where you can get a text message. *

What vaccination or test are you requesting: *

Covid-19 Vaccination

Covid-19 Rapid Nasal Swab Test (15min)$99

Health Insurance information (Insurance Company Name, Member ID, Group #, Medicare #)

Is this your first or second shot? *

First shot

Second shot

Neither - Requesting Rapid Test

If requesting second vaccination shot, what was the date of your first shot and which brand did you receive?

Please answer the following questions to the best of your ability. Answering "yes" to any of the questions does not necessarily preclude you from vaccination, but you might be asked follow-up questions to clarify your response.

Have you ever had a serious reaction to any vaccination, ie. anaphylaxis? *

Yes

If yes, please explain serious reactions.

Do you currently have any chronic health problems (Diabetes, Asthma, Heart Disease, etc) *

Yes

If yes, please explain any chronic health problems.

Are you currently immunocompromised? (Cancer, AIDS/HIV, or other immunological disorder) *

Yes

If yes, please explain any how immunocompromised.

Are you a First Responder, Front Line Healthcare Worker, Teacher or Child Care Worker?*

Yes

If yes, please give name and address of employer:

Have you received vaccinations in the last 4 weeks? *

Yes

If yes, please give details.

You will receive an email confirmation of your appointment request. Thank You.