PLEASE READ ALL INFORMATION BEFORE YOU COMPLETE THIS FORM.

1. Please complete the form below only once. Multiple entries may delay your appointment.  

** Please provide a working cell phone and email address you check often. **

2. You are REQUIRED to bring the "COVID-19 Vaccination Record Card" that you were provided when you received your first dose of the Moderna vaccine.

The listed date on your "COVID-19 Vaccination Record Card" for your 2nd dose is only the 1st day that you are allowed to receive your 2nd dose and is NOT intended to be the exact day that you can receive your 2nd dose.

3. Bring your health insurance information if you have it.

Receiving the COVID vaccine is free; however, there are costs associated with providing this service to the community, including supplies and staffing, that are being absorbed by NET Health.

The NET Health Immunizations Department asks that you bring proof of health insurance on the day that you return for your 2nd appointment, so that we can bill your health insurance provider to help us cover these administrative costs of providing the Moderna vaccine to you free of charge.

3. Completion of the form below DOES NOT schedule you for an appointment. NET Health will directly contact you to schedule your 2nd appointment. Please be patient because we have to ensure we have enough clients that can be scheduled for 2nd Dose Moderna vaccines.

When you receive our invitation to make an appointment, you may THEN sign up for your second dose of the Moderna vaccine.  

4.  Thank you again for trusting NET Health with your health!