Covid-19 Vaccination Request

    Before Scheduling a Vaccine



  • Have you tested positive for and/or been diagnosed with COVID-19 infection within the last 14 days? YesNo
  • Have you been in close contact with anyone who tested positive for and/or has been diagnosed with COVID-19 infection within the last 14 days? YesNo
  • Do you currently have fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea, vomiting, or diarrhea? YesNo


  • Type of Appointment?


  • If possible, vaccine preference?


  • I affirm that I have answered these questions truthfully and to the best of my knowledge and acknowledge that I may be asked to verify my eligibility information at my appointment. I also affirm that I will only book an appointment in the state for which I have answered these eligibility questions.

  • *You CAN'T choose the COVID-19 vaccine you receive. It will be determined by what inventory is available at the time of vaccination.
  • *One-dose Vaccine: During this session, you will schedule one appointment date within a range of available dates. The dose will be the complete vaccine.

  • *Two-dose Vaccine: During this session, you will schedule two separate appointments. The timing of both equally important doses is recommended by medical experts. The date of your second visit will be determined by the date of your first visit. The second dose is mandatory for vaccination completion.

  • *You may need: The vaccines are no cost to you, but we will need to bill your insurance provider or the government. So, grab your insurance card(s). If you do not have insurance, we will ask for a valid social security number and/or a driver's license/state ID number.



  • Information About Patient


  • Full Name:
  • Date of Birth:
  • Phone Number:
  • Address:
  • City, State and Zip:
  • Name of Legal Guardian:
  • Sex: (Gender assigned at birth) MaleFemale
  • Race:

  • Primary Insurance Carrier ID #:
  • Group #:
  • Insurance Company:
  • Insurance Company Phone:
  • Insured’s Name:
  • Insured Relationship
  • Insured Date of Birth:

  • Secondary Insurance Carrier ID #:
  • Group #:
  • Insurance Company:
  • Insurance Company Phone:
  • Insured’s Name:
  • Insured Relationship:
  • Insured Date of Birth:
  • Preferred Appointment Date:
  • Appointment Time:
  • Secondary Appointment Date, If not available:
  • Appointment Time:

    * Required

  • Thank you for your Covid-19 Vaccination Appointment Request. Someone will contact you shortly to confirm your appointment.