COVID-19 Vaccine Waitlist

Thank you for taking the time to complete this form. This waitlist form is for individuals who are interested in receiving a vaccine at a Community Vaccine Clinic hosted by Boston Medical Center. Submitting this form does not guarantee an appointment.

After you submit the form, we will call, email or text you to schedule an appointment once you are eligible for a vaccination according to Massachusetts guidelines. Due to supply, it might take several weeks until you are notified about an appointment, even if you are eligible for a COVID-19 vaccination. You can schedule yourself online for an appointment here if you are eligible.

Please note:

Only people who are eligible for vaccination will receive a phone call, text or email to schedule an appointment.
Submitting this form does not guarantee an appointment. If you are able to get an appointment through another channel, please get vaccinated through that channel, even if you have already filled out the form.
Please only include information for one person on each form.

If you have questions about the COVID-19 vaccine, please speak to your primary care provider or visit BMC.org, where you can find answers to many questions about COVID-19 vaccines, such as how the vaccine works and information for people with specific health conditions.

Are you filling this form out for yourself or on behalf of someone else?
For Myself
On behalf of someone else

Are you interested in receiving a COVID-19 vaccine?* Yes No

First Name*

Last Name*

Date of Birth (MM/dd/yyyy)*

Preferred Language*

Zip Code of residence or where primary care is received*

If other, what zip code

Phone Number (mobile preferred if applicable)*

Are you able to quickly (within 1 hour) come to our Boston vaccine locations if last-minute vaccine supply is made available?*
Yes No

Are you a BMC primary Care Patient?*
Yes No

Age group*

COVID-19 Vaccine Waitlist

Please provide your own contact information.

Please fill out the following information for the person you are assisting.

Which priority group do you or the person you’re filling out the form for belong to? If you do not fill out this question, we may not be able to contact you when you’re eligible for a vaccine.