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COVID-19 VACCINE

Call Us 914-341-1900

2141 Palmer Ave, Larchmont NY 10538

Operating Hours

M - F: 8:00am - 7:00pm, Sat: 9am - 6pm,

Sun: 9:00am - 4:00pm

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COVID-19 VACCINE

COVID-19 VACCINE REGISTRATION

COVID-19 VACCINATION REGISTRATION

Full Name

Date of Birth

Email Address

Phone Number

Street Address

City

State

Are you 18 years of age or older?

Yes

No

Do you currently or have you in the past 14 days, had a fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting or diarrhea?

Yes

No

Have you tested positive for COVID-19 within the past 14 days?

Yes

No

Which vaccine are you requesting?

Moderna

Pfizer

What are your vaccination needs?

I need to start Vaccination (I've never received a COVID-19 vaccine before)

I only need to schedule a second dose (I have already received a first dose)

I need to schedule an extra (third) dose [This option is for patients with Moderate to Severely weakened immune systems only]

Free Text

Click here to see who qualifies for a third dose

Which COVID-19 vaccination have you received in the past

Pfizer

Moderna

J&J (Janssen)

None

Thank you for registering. A member of our staff will promptly call you to make an appointment to receive your vaccine.

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Email Address

First Name

Last Name

Thank you for contacting us.
We will get back to you as soon as possible

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Store Hours

Mon - Fri: 8:00am - 7pm

Saturday: 9am - 6pm

Sunday: 9:00am - 4:00pm

Larchmont Pharmacy

2141 Palmer Ave

Larchmont, NY 10538

(914) 341-1900

Westchester Pharmacy Group

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