Jump to Content
 

Available Forms

Covid Vaccine Request Form

This will add you to our waitlist for shots beginning week of 4.15.21. This does not guarantee a spot. When we have a shot you will receive a link from DHHS to register for shot. Once you complete that registration you can come back to patient portal and schedule a shot under the COVID Vaccine Calendar in the portal tab. If you schedule prior to registering with DHHS your appointment will be deleted and you will be moved to back of wait list.

Email is required by DHHS to track your vaccine . Please enter your current email. If you don't have an email - NONE
If you don't have a home phone that is not a cell enter - none
If you don't have a cell - then enter none
IF not patient of Cary Adult Medicine please complete
If not a patient at Cary Adult Medicine please complete
This would include a severe allergic reaction that required treatment with Epipen or caused you to go to hospital or reaction that caused hives swelling or respiratory distress including wheezing

In order to register your shot with the NC DHHS , we need you to answer the following questions required in the NC DHHS data bank .

This will add you to our waitlist for shots beginning week of 4.15.21. This does not guarantee a spot. When we have a shot you will receive a link from DHHS to register for shot. Once you complete that registration you can come back to patient portal and schedule a shot under the COVID Vaccine Calendar in the portal tab. If you schedule prior to registering with DHHS your appointment will be deleted and you will be moved to back of wait list.

* Required field