COVID Vaccine Appointment Request
If you are
requesting an appointment for COVID
Vaccine, please fill out this form and
we will try our best to accommodate your request
in the order we receive it. This is
contingent upon the availability and
the number of doses we receive each
week. If you have multiple children
in the family, please add those
names and DOBs in the Message field.
Please submit only one form per
Currently, we are only
administering Pfizer Vaccines (30 mcg/0.3ml
for 12+years, 10 mcg/0.2ml for ages between
5 and 11 years).
Please do not
call the office for confirmation/request of
appointments. We will notify you
through email/text messages. We do
not want to overwhelm
our front desk staff who need to
dedicate their time to take care of the
sick patients. Thank you for your
the consent form and bring it with
you at the time of the appointment.
You need ONE CONSENT FORM FOR EACH
child who gets the immunization.
Also, please read the Vaccine
Information Sheet and if you have
any question, you may bring it to
the attentions of the provider at
the time of the appointment.
Vaccine Information Sheet