COVID-19 Vaccine Reservation

Please select a location to receive your COVID-19 vaccine. * = required

Select Location*

Select Day*

Select Time*

Please fill out your personal information and answer the following questions before confirming your reservation:

First name*

Last name*

Date of birth*

Gender*

Race*

Ethnicity*

Address*

City*

State*

Zip code*

Email*

Phone number*

Household income*

Select one of the following*

If this is your second dose, please specify which first dose vaccine you received

Please mark what applies to you (Note, you do not need insurance to receive the vaccine)*

Are you pregnant? (if yes, please speak to your OB/GYN doctor prior to your visit)*

Have you tested positive for COVID-19 in the last 14 days?*

Have you received any other vaccine in the past 14 days?*

Have you had any reactions to vaccines in the past such as feeling lightheaded, woozy/nauseous, passing out, or anaphylaxis? (if yes, you may be asked to wait an additional 15 minutes post vaccine)*

Do you have any allergies towards shellfish/bee stings? (if yes, you may be asked to wait an additional 15 minutes post vaccine)*

Other allergies

If you have any questions, please contact the Wildhealth Help Desk: (859) 217-4679

Or click this link to view our FAQ; https://kyvax.com/FAQ