• COVID -19 Vaccine Appointment Form

  • Patient Information

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  • The Pfizer vaccine has received Emergency Use Authorization for individuals age 12 and up.  You do not meet the age requirement at this time, so we are unable to schedule you for an appointment.

  • APPOINTMENT LOCATION: ____________________

  • PFIZER: You/Your child's first dose of Pfizer COVID-19 vaccine will be given on ________ at the appointment time you pick below. You/Your child's appointment for the second dose will automatically be scheduled for the SAME appointment time on _________ at __________. PLEASE MAKE SURE BOTH APPOINTMENT DATES/TIMES/LOCATIONS WILL WORK FOR YOU BEFORE SCHEDULING.

  • MODERNA: Your first dose of Moderna COVID-19 vaccine will be given on ________ at the appointment time you pick below. Your appointment for the second dose will automatically be scheduled for the SAME appointment time on _________ at __________. PLEASE MAKE SURE BOTH APPOINTMENT DATES/TIMES/LOCATIONS WILL WORK FOR YOU BEFORE SCHEDULING.

  • REMINDER: Write your appointment dates - first and second dose (if applicable) and time on your personal calendar!  Then press the "Submit" button (below) ONE TIME.

  • Should be Empty: