Get My Shot | CHC/SEK

First Name*

Last Name*

Date Of Birth*

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Preferred Location*

Select your desired location from the drop down list above.

Do you have a preferred day of the week?*

Will this be your first or second dose?*

Which vaccine did you receive on your first dose?

When was your first dose administered?

Do you have a preferred Vaccine?*

COVID Vaccination Form