Please indicate if you qualify within the Phase 1A categories:
Please indicate your eligibility for the Governor's Phase 1B+ below:
Please indicate your eligibility for the Governor's Phase lC below:
*Please note- this form does NOT sign you up for an appointment. but will add you to our COVID Vaccine contact list.
*Patients will be notified by our office with a phone call when eligible to receive the vaccine and will
receive a follow-up email from our office with the scheduling link.
Thank you for your patience as we work diligently through our extensive lists with limited vaccine slots.