COVID-19 Vaccine Request Form

Genesis Health Care is working rapidly to provide COVID-19 vaccine to phase 2 individuals and SC residents age 16+. At this time, Genesis is only administering the Moderna vaccine, which is approved for individuals 18+. If you are eligible, please complete the form below to request a vaccine appointment.

Remember:

  • Be patient. We are working hard on all of the details in an environment that is changing rapidly. There may be a delay before you receive an email from the CDC to register and schedule your appointment using their VAMS portal. 
  • Do not submit multiple vaccine request forms. 
  • Do not call individual practices about vaccines.
  • Appointments will be based on the limited supply of vaccine available.

If you need to create an email address, you can create an email for free with Google. 

IF YOU ARE CURRENTLY ELIGILE TO RECEIVE A COVID-19 VACCINE, PLEASE COMPLETE THE FOLLOWING FORM TO REQUEST AN APPOINTMENT. INDIVIDUALS MUST PROVIDE EITHER A UNIQUE EMAIL ADDRESS OR MOBILE PHONE NUMBER:

Please note: Genesis is only administering Moderna vaccines at this time, which is approved for individuals 18+.






    Do you meet the criteria for Phase 2?