Name
*
First Name
Last Name
Birthdate
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Kohl's QuadMed Location
*
DeSoto, TX
Ottawa, IL
Winchester, VA
Do you have a QuadMed MyChart account?
*
Yes
No
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Appointment
Time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
The information collected will be used by QuadMed for the purpose of ordering supply of the vaccine and notifying you when you are eligible to schedule an appointment for the vaccine, based on the criteria set forth by the CDC and state guidance.
SUBMIT
Should be Empty: