Covid-19 Vaccine Questionnaire

Please fill out the form and answer the questions below. We will organize people by phase and reach out to schedule a vaccine appointment when vaccines become available.

Personal Information
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Phone Number*
Address
Street Address Address Line 2 City State ZIP Code
Questionnaire
Essential Workers*
Are you a licensed, registered, and certified healthcare provider, nursing home staff member, law enforcement member, firefighter, EMS, first responder, correctional healthcare staff, or a front-line judiciary staff?
- Yes
- No
75 or older*
Are you 75 years or older OR are you in K-12 education, living at a facility for the elderly or behavioral health patients?
- Yes
- No
65-74 years old*
Are you 65-74 years old OR do you work in public health, safety, lab service, food production, manufacturing, postal service, public transit or a grocery store?
- Yes
- No
Are you age 60 or older?*
- Yes
- No
16 or older with underlying medical condition*
Are you age 16 and older with an underlying medical condition that puts you at increased risk for COVID-19 illness (Cancer, Kidney Disease, COPD, Down Syndrome/Developmental disorder, Heart Condition such as heart failure, artery disease, cardiomyopathies), Immunocompromised from organ transplant, Obese (BMI>30), Pregnancy, Sickle Cell, Smoker, Type 2 Diabetes)
- Yes
- No
55 or older*
Are you age 55 or older OR considered an essential worker in critical industries (restaurants, utilities, construction, transportation, financial services, IT and other infrastructure)?
- Yes
- No
Are you 16 and older?*
- Yes
- No

Hours & Locations

Whitesell Pharmacy
236 North Market St.
Frederick, MD 21701
View Map

Phone: 301.662.4848
Fax: 301.620.0668

Hours
8:30AM – 5:00PM
Monday – Friday

8:30AM – 2:00PM
Saturday

Whitesell Home Medical Supply
622 N. Market Street
Frederick, MD 21701
View Map

Phone: 301.663.6464
Fax: 301.663.3207

Hours
8:30AM – 5:00PM
Monday – Friday

Closed Saturday

Please click here for our HIPPA Notice of Privacy Practices

Quick Links
Retail Pharmacy Services
Home Medical Supply
Prescriptions
Long Term Care Services
Breast Pumps
Insurances We Accept
HIPAA Disclosure

Whitesell Pharmacy
236 North Market St.
Frederick, MD 21701
Phone: 301.662.4848
Fax: 301.620.0668

Hours
Monday – Friday: 8:30AM – 5:00PM
Saturday: 8:30AM – 2:00PM

Whitesell Home Medical Supply
622 N. Market Street
Frederick, MD 21701
Phone: 301.663.6464
Fax: 301.663.3207

Hours
Monday – Friday: 9:00AM – 5:00PM
Closed Saturday

Covid-19 Vaccine Questionnaire

Personal Information

Questionnaire