COVID-19 VACCINATION REGISTRATION COVID BOOSTER Appointment FULL REGISTRATION 0% Complete1 of 4 This is the registration portal for Hayden's Pharmacy COVID-19 Vaccinations. PLEASE COMPLETE THE FOLLOWING: REGISTRATION CODE SENT VIA EMAIL: (IF YOU DO NOT RECEIVE THIS CODE VIA EMAIL, PLEASE PROCEED TO THE NEXT QUESTION) Patient First Name * Patient Last name * Patient Gender * Male Female Patient Date of Birth * Patient Race * American Indian Or Alaska Native Asian Black or African American Native Hawaiian Other Pacific Islander White Other Patient Race Patient Ethnicity * Hispanic or Latino Not Hispanic or Latino Patient Address * Apartment, Suite, or Floor City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming County * Adams Allegheny Armstrong Beaver Bedford Berks Blair Bradford Bucks Butler Cambria Cameron Carbon Centre Chester Clarion Clearfield Clinton Columbia Crawford Cumberland Dauphin Delaware Elk Erie Fayette Forest Franklin Fulton Greene Huntingdon Indiana Jefferson Juniata Lackawanna Lancaster Lawrence Lebanon Lehigh Luzerne Lycoming McKean Mercer Mifflin Monroe Montgomery Montour Northampton Northumberland Perry Philadelphia Pike Potter Schuylkill Snyder Somerset Sullivan Susquehanna Tioga Union Venango Warren Washington Wayne Westmoreland Wyoming York If you are not from PA, please enter your county County Zip Code * Contact information An active email and phone number is required so you can receive communication and information on your request for COVID-19 vaccination and COVID-19 follow-up vaccination communication. Patient's Email * Patient's Cell Phone * Next
