Patients Personal Details
Please fill out this HIPPA Compliant form below. Only submit once. Please send us a message on Facebook page if you need further assistance. Please bring your Medicare RED WHITE BLUE card or your prescription card if available. Your insurance pays us a small administration fee. There is no charge for the Covid vaccines. The consent form can be found on www.deeflatrx.com
Moderna 2nd shot is due 28 days (preferred) to 42 days after your 1st shot.
When and where did you get your 1st Moderna shot?
Email reminder 24 hours prior to your appt
To minimize wait time, please upload a photo ID or DL - this will be kept confidential
Please take a photo of your Medicare ID (red-white-blue card) or prescription card (AHCSS or BCBS etc)
CONFIRM APPOINTMENT - PLEASE ONLY SUBMIT ONCE
Should be Empty: