Reservation Removal Request – York Hospital Age – Eligible Vaccine Appointment Registration

YORK HOSPITAL COVID-19 VACCINE
WAITING LIST RESERVATION REMOVAL REQUEST FORM

If you’ve already received your Covid-19 vaccine, or have a confirmed appointment at another vaccination site, and would like to remove your name from York Hospital’s Covid-19 Vaccine Clinic Reservation Waiting List, please complete the following form. We appreciate your help in keeping our list up to date and allowing other community members to receive their vaccines more quickly.

If you prefer to speak with someone via telephone for assistance in removing your name, please call us at (207) 752-8685, 8 a.m. – 5 p.m., Monday – Friday.

For our deaf or hard of hearing community members, our TTY contact number is (207) 363-7433.

Thank you for your help. . .
York Hospital’s Care Access Team

Name*
First Last
Date of Birth*
Month
Day
Year
Confirmation*
- I understand that by submitting this form, I am requesting to have my name permanently removed from the York Hospital COVID-19 Vaccine Waiting List. If my circumstances change and I need to sign up again, my place on the list will be determined by the date and time of my new sign-up.

YORK HOSPITAL COVID-19 VACCINEWAITING LIST RESERVATION REMOVAL REQUEST FORM

YORK HOSPITAL COVID-19 VACCINE
WAITING LIST RESERVATION REMOVAL REQUEST FORM