• social information if applicable

After submitting the form, we will verify your information in our database. Once confirmed that you are an existing patient and meet current eligibility criteria, we will contact you by phone or text to schedule an appointment. Due to the high demand for the vaccine, it may take several days to contact you. 

To prevent delays, we recommend the following tips when filling out the form. 

  • One form per patient
  • Do not use nicknames
  • Check for misspellings
  • Place caregiver information in "Contact Information"

Appointment Request Form