www.covid19pfizer.com Open in urlscan Pro
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Form analysis
1 forms found in the DOM

Name: signup — POST /

<form name="signup" action="/" method="post" onsubmit="return formValidate()" class="signupform" id="signupform">
  <div class="form-field dob">
    <label for="DOB" class="label-dob m_date-bottom-ca">Date of Birth</label>
    <span class="shell"><span aria-hidden="true" id="DOBMask"><i></i>MM/DD/YYYY</span><input id="DOB" type="tel" name="DOB" class="inputdob masked" pattern="(1[0-2]|0[1-9])\/(0[1-9]|1[0-9]|2[0-9]|3[0-9])\/(1[0-9][0-9][0-9]|20[0-2][0-9])"
        data-valid-example="12/24/2002" maxlength="10" data-placeholder="MM/DD/YYYY"></span>
    <div id="DOB_error" class="error"><i class="error-icon"></i>Please enter your date of birth</div>
  </div>
  <div class="form-field zip-code">
    <label class="label-zipcode m-bot-zip-ca" for="zip_code">ZIP Code</label>
    <input placeholder="e.g. 10001" type="text" name="ZipCode" maxlength="5" minlength="5" class="zipcode" id="zip_code" index="4" oninput="this.value = this.value.replace(/[^0-9.]/g, '').replace(/(\..*)\./g, '$1'); ">
    <div id="zipcode_error" class="error"><i class="error-icon"></i>Please enter your ZIP code</div>
  </div>
  <div class="content-margin-ca">
    <h3 class="interests_mb-ca">What are you most interested in?</h3>
  </div>
  <p class="content-header-p-ca">I am interested in information for people who are (select all that apply):</p>
  <div id="age_checkbox_error" class="error interested-p"><i class="error-icon"></i>Please select at least one option</div>
  <div class="age-info">
    <div class="checkbox checkbox-1">
      <input type="checkbox" id="sixtyfive" name="sixtyfive" value="65+ years of age" index="5A" class="agecheckbox">
      <label for="sixtyfive">65 years of age and older</label>
    </div>
    <div class="checkbox checkbox-2">
      <input type="checkbox" id="fiftytosixtyfour" name="fiftytosixtyfour" value="50-64 years of age" index="5B" class="agecheckbox">
      <label for="fiftytosixtyfour">50 to 64 years old</label>
    </div>
    <div class="checkbox checkbox-3">
      <input type="checkbox" id="eighteentofortynine" name="eighteentofortynine" value="18-49 years of age" index="5C" class="agecheckbox">
      <label for="eighteentofortynine">18 to 49 years old</label>
    </div>
    <div class="checkbox checkbox-4">
      <input type="checkbox" id="twelvetoseventeen" name="twelvetoseventeen" value="12-17 years of age" index="5D" class="agecheckbox">
      <label for="twelvetoseventeen">12 to 17 years old</label>
    </div>
    <div class="checkbox checkbox-5">
      <input type="checkbox" id="fivetoeleven" name="fivetoeleven" value="5-11 years of age" index="5E" class="agecheckbox">
      <label for="fivetoeleven">5 to 11 years old</label>
    </div>
    <div class="checkbox checkbox-6">
      <input type="checkbox" id="sixmotofouryr" name="sixmotofouryr" value="6 months–4 years of age" index="5F" class="agecheckbox">
      <label for="sixmotofouryr">6 months to 4 years old</label>
    </div>
    <div class="checkbox checkbox-7">
      <input type="checkbox" id="immunocompromised" name="immunocompromised" value="Immunocompromised" index="5G" class="agecheckbox">
      <label for="immunocompromised">Immunocompromised</label>
    </div>
  </div>
  <p class="disclaimer">Pfizer understands your personal and health information are private. The information you provided will be used by Pfizer and parties acting on its behalf to send you communications in accordance to <nobr>Pfizer’s <strong
        class="open-sans-bold"><a href="https://www.pfizer.com/policy" target="_blank">Privacy Policy</a></strong></nobr>.</p>
  <div class="checkbox-div-18 checkbox-18 flex-item">
    <input type="checkbox" class="chck-input left-width-box-ca-page" id="check_box" index="7" value="Yes">
    <label class="form-check-label" for="check_box" id="errMsg">By checking this box, I agree that I am 18 years of age or older.</label>
  </div>
  <div id="checkbox_error" class="error">Select to acknowledge agreement</div>
  <div class="signupbutton-ca">
    <input type="submit" value="Sign Me Up!" class="btn" index="8">
  </div>
</form>

Text Content

COLLECTIVE ADVANTAGE PAGE




COLLECTIVE ADVANTAGE PAGE


JUST A FEW QUICK STEPS BEFORE
YOU'RE SIGNED UP

About you

All fields are required unless otherwise stated.

Date of Birth MM/DD/YYYY
Please enter your date of birth
ZIP Code
Please enter your ZIP code


WHAT ARE YOU MOST INTERESTED IN?

I am interested in information for people who are (select all that apply):

Please select at least one option
65 years of age and older
50 to 64 years old
18 to 49 years old
12 to 17 years old
5 to 11 years old
6 months to 4 years old
Immunocompromised

Pfizer understands your personal and health information are private. The
information you provided will be used by Pfizer and parties acting on its behalf
to send you communications in accordance to Pfizer’s Privacy Policy.

By checking this box, I agree that I am 18 years of age or older.
Select to acknowledge agreement


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Manufactured for BioNTech Manufacturing GmbH An der Goldgrube 12 55131 Mainz,
Germany Emergency Use Authorization Holder

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Terms of Use
Privacy Policy
Contact Us

COVID-19 vaccines from BioNTech and Pfizer, which are based on BioNTech
proprietary mRNA technology, were developed by both BioNTech and Pfizer.

© 2023 Pfizer Inc. All rights reserved. PP-CVV-USA-2377

This site is intended only for US residents. The products discussed in this site
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provided is for educational purposes only and is not intended to replace
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