Glove

COVID-19 Vaccines

Schedule an Appointment

Pre-Registration Form

Please use the form below to complete your online request for the COVID-19 vaccine. You will be contacted by phone with instructions, appointment information and options available. Support documentation may be requested from you. Appointments are made in order of receipt. We appreciate everyone’s patience as we work toward vaccinating as many people as possible.

Sex
Race
Ethnicity
Please select one
Preferred Language?
Do you have any allergies?
Appoinment Availability
Choose a time
Vaccine preference?
Have you ever received a dose of COVID-19 vaccine?
If yes, is this your 1st or 2nd dose?
Which vaccine were you given?

I acknowledge that I am the patient or authorized representative of the patient wishing to obtain a COVID-19 vaccine. I understand and authorize that by requesting the scheduling of an appointment for myself or the patient for the COVID-19 vaccination through this website, Care4U may receive my protected health information and personal identifying information. I also authorize Care4U to share my information as necessary or requested, for continuity of treatment or registry purposes

Please right click with your mouse to sign.