Vaccine Appointment Request Form

Please complete the form below and a member of our team will follow up with the individual to schedule a COVID-19 Vaccine Appointment when available based on weekly state allocation and eligibility. Please submit each name only once, multiple submissions could delay scheduling.

This link has specifically been given to those in community assisting with efforts to equitability distribute the vaccine to our underserved and minority community members. THIS LINK IS NOT TO BE SHARED.