Schedule a Vaccination

Vaccinations are available from Monday to Friday, 10 PM to 4 PM. You may schedule up to two vaccinations per appointment. We'll need to gather your patient information to begin.

Patient Information

First Name*
Last Name*
Date of Birth (DD/MM/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?
Do you have any allergies to medications, food (i.e. eggs), latex, vaccine components (e.g. Neomycin, Formaldehyde, Gentamicin, Thimerosal, Bovine Protein, Phenol, Polymyxin, Gelatin, baker's yeast or yeast)?
Do you have any allergies to medications, food (i.e. eggs), latex, vaccine components (e.g. Neomycin, Formaldehyde, Gentamicin, Thimerosal, Bovine Protein, Phenol, Polymyxin, Gelatin, baker's yeast or yeast)?
Have you ever had a serious reaction to any vaccinations, including fainting and feeling dizzy?
Have you ever had a serious reaction to any vaccinations, including fainting and feeling dizzy?
Have you ever had a health problem with lung, heart, kidney or metabolic disease (e.g., diabetes), asthma, or a blood disorder?
Have you ever had a health problem with lung, heart, kidney or metabolic disease (e.g., diabetes), asthma, or a blood disorder?
Have you ever had a seizure disorder for which the patient is on seizure medication(s), a brain disorder, Guillain-Barré syndrome (a condition that causes paralysis) or other nervous system problem?
Have you ever had a seizure disorder for which the patient is on seizure medication(s), a brain disorder, Guillain-Barré syndrome (a condition that causes paralysis) or other nervous system problem?
For Women: Are you pregnant or considering becoming pregnant in the next month?
For Women: Are you pregnant or considering becoming pregnant in the next month?

Have you had the following vaccines?

Pneumococcal Vaccine
Have you had the Pneumococcal Vaccine?
Shingles Vaccine
Have you had the Shingles Vaccine?
TDAP (Whooping Cough) Vaccine
Have you had the TDAP (Whooping Cough) Vaccine?

Schedule Vaccination

Vaccinations are available from 10 AM - 4PM, Mon-Fri. Not available on federal holidays. Please choose a time for your appointment.
Mon, Nov 30
Mon, Nov 30
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
03:00 PM
03:15 PM
03:30 PM
03:45 PM
Tue, Dec 1
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
03:00 PM
03:15 PM
03:30 PM
03:45 PM
Wed, Dec 2
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
03:00 PM
03:15 PM
03:30 PM
03:45 PM
Thu, Dec 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
03:00 PM
03:15 PM
03:30 PM
03:45 PM
Fri, Dec 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
03:00 PM
03:15 PM
03:30 PM
03:45 PM
Weekend

PATIENT AGREEMENT AND CERTIFICATION

Signature (type your full name)*
Date