Hindu Temple of KC / Appointments for Covid Vaccination
Email (Must have for appointment confirmation)
* Required
Email address
*
Your email
Please read carefully
Filling this form to request an appointment is not a guarantee you will get one. We will only forward information to Medical facility and they will reach out to you if a slot is available based on criteria.
Only one request per person. Multiple requests for the same person will be rejected.
If you had already submitted a request, no need for another one.
If you want to update details submitted, check your acknowledgement email for steps.
First Name
*
Your answer
Last Name
*
Your answer
Date of Birth (Must be 65 or older)
*
If you are below 65 years, your information will not be processed.
MM
/
DD
/
YYYY
Street address
*
Your answer
City
*
Your answer
State
*
Kansas
Missouri
ZIP
*
Your answer
Phone number
*
Your answer
Gender
*
Female
Male
Appointment session
*
Morning
Afternoon
A copy of your responses will be emailed to the address you provided.
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