Schedule a Vaccination

Covid-19 vaccinations are available from Monday to Friday, 10 PM to 3 PM.
We are only offering Covid-19 vaccines at this time. We are currently administering the Moderna vaccine. The vaccine will be no cost for you. We will either bill your insurance card or the government. Please, have your insurance card with you.
It is very important to be on-time, wearing a mask, and dressed appropriately. 
YOU MUST BE 18 YEARS OR OLDER TO RECEIVE THE VACCINE. 

Patient Information

First Name*
Last Name*
Date of Birth (MM/DD/YYYY)*
Age*
Gender
Please Choose...
Email*
Contact Phone Number*
Home Address*
Address Line 2
City*
State
Zip Code*
Primary Care Physician
Physician Phone
Insurance Card
Upload an image of your insurance card or bring it to your appointment.
Vaccines To Receive At Your Appointment (Max 2)
Vaccines To Receive At Your Appointment (Max 2)

Screening Questionaire

The following questions will help us deermine your eligibility to be vaccinated.
Are you feeling sick or experiencing a moderate to high fever?
Are you feeling sick or experiencing a moderate to high fever?
Are you currently in isolation for COVID-19 infection or known exposure to COVID-19?
Are you currently in isolation for COVID-19 infection or known exposure to COVID-19?
Have you ever received a COVID-19 vaccine?
Have you ever received a COVID-19 vaccine?
Have you had any allergic anaphylactic reaction to any allergen, injected medication (including other vaccines)?
Have you had any allergic anaphylactic reaction to any allergen, injected medication (including other vaccines)?
Have you ever had an allergic reaction to polyethylene glycol (PEG) or polysorbate?
Have you ever had an allergic reaction to polyethylene glycol (PEG) or polysorbate?
Have you received monoclonal antibodies or convalescent plasma as part of COVID-19 treatment within the last 90 days?
Have you received monoclonal antibodies or convalescent plasma as part of COVID-19 treatment within the last 90 days?
Do you have a bleeding disorder or are you on a blood thinner?
Do you have a bleeding disorder or are you on a blood thinner?
Are you immunocompromised or are you on medicine that affects your immune system or have a history of Guillian-Barre or Bell’s Palsy?
Are you immunocompromised or are you on medicine that affects your immune system or have a history of Guillian-Barre or Bell’s Palsy?
Do you have a history of using dermal filler?
Do you have a history of using dermal filler?
Have you had an immediate allergic reaction to a vaccine or injectable medication? (If yes, it is recommended to talk to your doctor)
Have you had an immediate allergic reaction to a vaccine or injectable medication? (If yes, it is recommended to talk to your doctor)
For women: Are you pregnant or considering becoming pregnant in the next month? (If yes, it is recommended to talk to your doctor)
For women: Are you pregnant or considering becoming pregnant in the next month? (If yes, it is recommended to talk to your doctor)
have you received any other vaccine in the past 14 days?
have you received any other vaccine in the past 14 days?

Have you had the following vaccines?

Schedule Vaccination

Covid-19 vaccinations are available from 10 AM - 3PM, Mon-Fri. Not available on federal holidays. Please choose a time for your appointment. IF ALL TIMES SLOTS ARE NOT HIGHLIGHTED OR CLICKABLE THAT MEANS WE ARE COMPLETELY BOOKED OUT.
Tue, Aug 3
Tue, Aug 3
10:00 AM
10:15 AM
10:30 AM
10:45 AM
11:00 AM
11:15 AM
11:30 AM
11:45 AM
12:00 PM
12:15 PM
12:30 PM
12:45 PM
01:00 PM
01:15 PM
01:30 PM
01:45 PM
02:00 PM
02:15 PM
02:30 PM
02:45 PM
Wed, Aug 4
10:00 AM
10:15 AM
10:30 AM
10:45 AM
11:00 AM
11:15 AM
11:30 AM
11:45 AM
12:00 PM
12:15 PM
12:30 PM
12:45 PM
01:00 PM
01:15 PM
01:30 PM
01:45 PM
02:00 PM
02:15 PM
02:30 PM
02:45 PM
Thu, Aug 5
10:00 AM
10:15 AM
10:30 AM
10:45 AM
11:00 AM
11:15 AM
11:30 AM
11:45 AM
12:00 PM
12:15 PM
12:30 PM
12:45 PM
01:00 PM
01:15 PM
01:30 PM
01:45 PM
02:00 PM
02:15 PM
02:30 PM
02:45 PM
Fri, Aug 6
10:00 AM
10:15 AM
10:30 AM
10:45 AM
11:00 AM
11:15 AM
11:30 AM
11:45 AM
12:00 PM
12:15 PM
12:30 PM
12:45 PM
01:00 PM
01:15 PM
01:30 PM
01:45 PM
02:00 PM
02:15 PM
02:30 PM
02:45 PM
Weekend
Mon, Aug 9
10:00 AM
10:15 AM
10:30 AM
10:45 AM
11:00 AM
11:15 AM
11:30 AM
11:45 AM
12:00 PM
12:15 PM
12:30 PM
12:45 PM
01:00 PM
01:15 PM
01:30 PM
01:45 PM
02:00 PM
02:15 PM
02:30 PM
02:45 PM

PATIENT AGREEMENT AND CERTIFICATION

Signature (type your full name)*
Date