Welcome to the BCH Vaccine Registration Page. If you are viewing this page, you have been referred to fill out the NYS Department of Health COVID-19 Vaccine Form in order to attest to your eligibility to receive the vaccine in advance of an appointment. Completing this form does NOT indicate you have or will be scheduled for a vaccine appointment by Bertrand Chaffee Hospital.
PLEASE READ THE FOLLOWING INSTRUCTIONS IN THEIR ENTIRETY BEFORE PROCEEDING:
1. Please click the link below and complete the form issued by the NYS Department of Health in its entirety. You will only need to complete this form before your first dose appointment.
2. Upon completion of the form, please print the confirmation page or the confirmation emailed to you (if you provided your email). You will need to present this confirmation at your vaccination appointment. If you do not have access to a printer, you may take a picture using your cell phone or forward your email confirmation to firstname.lastname@example.org.
3. Should you have any questions regarding this registration form, please contact the New York State COVID-19 Vaccination Hotline at 1-833-NYS-4-VAX (1-833-697-4829).