Please complete the vaccine request form listed below
to be added to our patient waiting list.
*THIS IS STEP #1*
COVID-19 Vaccine REQUEST FORM
After we receive this form, we will then review your PHASE status
and email the next step of the process.
-This process may take several days to complete if you are eligible.
-This process is based on VACCINE availability, current upcoming
appointment availability, and manpower.
If you are NOT eligible, you will be contacted when we enter your PHASE.
Please click HERE for details on Phase eligibility from Texas DSHS .
