Thank you for your interest in receiving the COVID-19 Vaccination.

This is NOT a reservation system.   Please know that filling out this form does not guarantee you will receive a call.

We are collecting information on those interested in receiving the vaccine, so that we may place your name on a stand-by list if there is extra vaccine or last-minute cancellations.

With each delivery of vaccine, the New York State Department of Health directs the hospital who may receive those doses.  Please kindly check all the categories below that you quality for to help us match vaccine to recipients.

We will keep all of your information private, and use only for purposes of matching you with a vaccine. 

While we will use this to contact you if there is vaccine available, we encourage you to continue to watch for opportunities on our www.bassett.org website AND continue to monitor the NYS reservation system to schedule yourself for an appointment.

Thank you again!  

Regards,
Your Bassett Healthcare Network Team

Question Title

* 1. Please provide us with the following:

Question Title

* 2. Please kindly check all of the criteria that you meet:

Question Title

* 3. Do you have access to internet (home or via cell phone)?

T