COVID-19 Pre-Registration Form

According to CDC Guidelines and Governor DeSantis’ Executive Order, eligible recipients include only:

  • Established patients that are 65 years and older.
  • Established patients that work in healthcare with direct patient contact.
  • Established patients that work in a long-term care facility.

Join Our Wait List

This form is used for our COVID-19 vaccination waitlist. We will contact you as eligibility is approved and supplies are available.


There is no cost to receive the Moderna COVID-19 Vaccine. Please check our website often and we will keep you informed every step of the way. In accordance with the State of Florida Department of Health Public Advisory (PRIORITIZATION OF FLORIDIANS FOR COVID-19 VACCINE IN FLORIDA), proof of Florida residency is required.

Please bring a government-issued ID (with birthdate) to your appointment for check-in. Upon arrival, registered individuals have an opportunity to read and sign the vaccine waiver, then will be called to the vaccination area.

All individuals receiving vaccines will be asked to wait in an observation area for at least 15 minutes with medical staff to ensure there are no adverse initial reactions. Those receiving the vaccine may experience some side effects such as pain at the injection site, fever, chills, tiredness, headache, and/or body aches. You will be contacted for second dose appointments.