A representative will contact you within one business day to set up your appointment. If this is an emergency, call 911 or go to your nearest ER.

COVID-19 Vaccine

This form should not be used to make an appointment to receive the COVID-19 vaccine.
Learn how to make a COVID-19 vaccine appointment →

NOTE: With this form, you are submitting a request for appointment. A representative will contact you once an appointment has been secured or, if necessary, to discuss alternative options.

Appointment Information
Insurance Information
Contact Information
E.g. willing to see a different provider in order to match any preferred availability