COVID-19 Vaccine Appointment Registration
Please fill out the form below to schedule your appointment.
**Important** Corticosteroid use within 90 days of your vaccination may cause adverse reactions to the vaccination. If you have taken any corticosteroids recently, your appointment needs to be 90 days after your last dose. (Examples include, but are not limited to: dexamethasone, hydrocortisone, methylprednisolone, prednisolone, and prednisone). If you have any questions about your medications and possible interactions, please check with your primary care physician to see if the vaccine is right for you at this time.
I have not taken any corticosteroids within 90 days of my appointment date.
Please enter a valid phone number.
Street Address Line 2
State / Province
Postal / Zip Code
Insurance ID/Medicare Polilcy Number
If you have private insurance or Medicare/Medicaid, please list your insurance company's address (usually found on the back of your insurance card).
The federal government is providing the vaccine at no cost. Our fee to administer the vaccine will be billed to your insurance company. If you do not have insurance coverage, a $35 administration fee will be collected during your appointment.
Select Your Appointment
Health and Medical History
Have you been diagnosed with COVID-19?
If so, when were you diagnosed with COVID-19?
Currently, we are only receiving doses of the Moderna vaccine. Will this vaccine be your first or second dose? (If this is your second dose, your first dose MUST have been a Moderna vaccine.) If this is your second dose, you will be required to present your vaccine card from your first dose when you arrive for your appointment.
Please list any allergies you may have. (Add one allergy at a time and then click "SAVE" after each entry).
I hereby declare that all the given information is accurate.
I hereby declare I am eligible to receive the COVID-19 vaccination.
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