Insurance Information
The vaccine is available at no cost to you. Insurance information is collected for administrative purposes. Bring your insurance card with you to appointment! If you do not wish to provide your insurance information, select "No Insurance"
Enter name of primary subscriber if relationship is not "self" of if name on card differs from recipient name entered above.
Enter address of primary subscriber if different than the recipient address entered above.
Emergency Contact (optional)
Primary Care Provider (optional)
Screening Questions
You are ineligible for the 3rd dose.
You are ineligible for the 3rd dose.
Please be sure to bring documentation of your prior vaccinations to the clinic.
You are ineligible for the 3rd dose.
If you are unsure if you have had a dose of COVID-19 vaccine before, please contact your healthcare provider.