Vaccine Registration

  • Please Select an Appointment

  • Which vaccine would you like to get?*

  • We currently have the MODERNA Covid vaccine. You are eligible if you are:

    • Age 65 and up
    • Under age 65 with an underlying condition 

    Please give us a call if you have any questions at 817-918-4900.

  • TEXAS IMMUNIZATION REGISTRY (ImmTrac2)ADULT/MINOR CONSENT FORM

  • Gender:*
  • Format: (000) 000-0000.
  • Do you have insurance?*
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  • Race (select all that apply)*
  • Ethnicity (select only one)*

  • Consent for Registration and Release of Immunization Records to Authorized Persons / Entities
    I understand that, by granting the consent below, I am authorizing release of my immunization information to DSHS and I further understand that DSHS will include this information in the Texas Immunization Registry. Once in ImmTrac2, my immunization information may by law be accessed by: a Texas physician, or other health care provider legally authorized to administer vaccines, for treatment of the individual as a patient; a Texas school in which the individual is enrolled; a Texas public health district or local health department, for public health purposes within their areas of jurisdiction; a state agency having legal custody of the individual; a payor, currently authorized by the Texas Department of Insurance to operate in Texas for immunization records relating to the specific individual covered under the payor’s policy. I understand that I may withdraw this consent at any time.

  • State law permits the inclusion of immunization records for First Responders and their immediate family members (older than 18 years of age) in the Registry. A “First Responder” is defined as a public safety employee or volunteer whose duties include responding rapidly to an emergency. An “immediate family member” is defined as a parent, spouse, child, or sibling who resides in the same household as the First Responder. For a family member younger than 18 years of age, a parent, legal guardian, or managing conservator may grant consent for participation as an “ImmTrac2 child” by completing the Immunization Registry (ImmTrac2) Consent Form (# C-7).

  • By my signature below, I GRANT consent for registration. I wish to INCLUDE my information in the Texas immunization registry.

  • Privacy Notification: With few exceptions, you have the right to request and be informed about information that the State of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. See http://www.dshs.texas.gov for more information on Privacy Notification. (Reference: Government Code, Section 552.021, 552.023, 559.003, and 559.004) 

    Questions? (800) 252-9152 • (512) 776-7284 • Fax: (866) 624-0180 • www.ImmTrac.com
    Texas Department of State Health Services • ImmTrac Group • MC 1946 • P. O. Box 149347 • Austin, TX 78714-9347

  • Prevaccination Checklist

    Please answer all questions to the best of your ability.
  • 1. Are you feeling sick today?*
  • 2. Have you ever received a dose of a COVID-19 vaccine?*
  • 3. Have you ever had an allergic reaction to: (This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.)*
  • 4. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication? (This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.)*
  • 5. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, or any vaccine or injectable medication? This would include food, pet, venom,environmental, or oral medication allergies.*
  • 6. Have you received any vaccine in the last 14 days?*
  • 7. Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?*
  • 8. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?*
  • 9. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?*
  • 10. Do you have a bleeding disorder or are you taking a blood thinner?*
  • 11. Are you pregnant or breastfeeding?*
  • 12. Do you have dermal fillers?*
  • Should be Empty: