Enter the dates you previously received vaccine doses for your initial series. If you did not receive a 3rd doses (3rd only applies to immunocompromised), leave that date blank.
The COVID-19 vaccine is available at no cost to you. Insurance information is collected for administrative purposes. Bring your insurance card with you to appointment!
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)
YOU WILL NOT BE ABLE TO EDIT THIS INFORMATION AFTER CLICKING THE SUBMIT BUTTON BELOW. PLEASE MAKE SURE ALL INFORMATION IS CORRECT.