AutoRemind

Today's Date:

Last Name:

First Name:

Date of Birth:

Age:

Parent(s) / Guardian(s) Name (Minors Only):

Mailing/Billing Address:

City:

State:

Zip Code:

Phone#

Email:

Please indicate if you qualify within the Phase 1A categories:

Highest-risk healthcare workers and first responders

Please indicate your eligibility for the Governor's Phase 1B+ below:

Highest-risk healthcare workers and first responders

Please indicate your eligibility for the Governor's Phase lC below:

Highest-risk individuals

Phase 2: General public

*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.

COVID Vaccine Contact List Form