COVID-19 Vaccine Request

PLEASE FILL OUT THE FORM BELOW. 

PLEASE NOTE: This does not guarantee an appointment. You will be added to a waiting list and called to schedule your vaccine as supplies are available. Walk-ins cannot be accommodated at this time.

Patients must show proof of age with driver’s license or proof of qualification such as Employee ID or name tag, pay stub, plan of care, or transplant card.

Pregnant patients or those with conditions that place them at high risk for complications from COVID-19 will be asked to complete a personal attestation form [pdf].

View a list of all groups currently eligible to receive the COVID-19 vaccine

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