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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 family.

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 cooperation.

Please download 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.

               Consent Form                Vaccine Information Sheet



Please complete the form bellow.


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