MIDCITIES Covid Vaccine Pre-Registration
MIDCITIES PHARMACY at 2000 Precinct Line Rd, Ste 102, Hurst, Texas 76054.
[UPDATE APRIL 22, 2021] TURNAROUND TIME is usually SAME DAY or NEXT DAY!
WE ARE ADMINSTERING THE MODERNA COVID and JOHNSON & JOHNSON JANSSENVACCINES RIGHT NOW. Pre-register here and we will reach out to you as slots fill up.]
If you need to sign up for the MODERNA SECOND ONLY: Sign up here -
We are asking you to PRE-REGISTER for the Covid Vaccination at MidCities Pharmacy. Once you sign up, we can get you in pretty fast. If you had pre-registered and not heard back in 2-3 days, please call the pharmacy. IMPORTANT NOTE: If you have no insurance, our policy is that you MUST provide either your SS# or Texas Drive License card (or TX ID card). We will turn you away in case you do not any of these.
NOTE: These will be administered in the our pharmacy at 2000 Precinct Line, Hurst TX 76054.
If you are representing a practice or organization, please indicate which one? If only yourself, then leave blank.
To make sure that you are not a robot, write the word "one" on this field. Anything else will reject your entry.
What is your address, city and ZIP? If you are close to us, we may use you as a backup on short notice.
Which category are you in?
65+ / Medicare
Under 65 with insurance
Under 65 without insurance
What is the best email for you? Email will be sent to everyone as it comes available. MAKE SURE THIS IS CORRECT.
What is a direct contact number for you (we will not be calling initially due to volumes requested). MOBILE number is BEST. Save our pharmacy number 817-605-3500 on your mobile phone
If this is Moderna, do you prefer your second dose on a FRIDAY (to avoid side effects)
No - sooner better
On your prescription insurance card, write ONLY the BIN and PCN number here. Don't write the ID or GROUP. If you don't have prescription insurance, write "NO INS". Do NOT write your personal information. You MUST provide your SS# and present your Texas ID card or Driver License if you do not have insurance. All insurances pay for the vaccine and it is zero out of pocket costs.
Will this be your first vaccine or second dose of the Covid Vaccine?
First - ANY *** RECOMMENDED
Second - Need Moderna
Second - Need Pfizer *** NOTE - WE DO NOT CARRY PFIZER AT THIS TIME.
First - Johnson&Johnson
If second vaccine is needed, WHEN and WHERE did you get your first one?
Never submit passwords through Google Forms.
This form was created inside of MidCities Pharmacy.