Moderna Covid Vaccine Pre-Registration
MIDCITIES PHARMACY at 2000 Precinct Line Rd, Ste 102, Hurst, Texas 76054.

[UPDATE JAN 23, 2021] WE ALREADY HAVE SEVERAL THOUSAND PEOPLE ON THE WAITLIST WHO HAVE PRE-REGISTERED. WE HAVE USED UP THE INITIAL DOSES THAT WE RECEIVED FROM THE STATE OF TEXAS AND ARE AWAITING MORE TO COME IN. WE DO NOT HAVE A TIME-FRAME WHEN THEY WILL SEND MORE.

*** WE RECOMMEND THAT YOU REGISTER WITH THE TARRANT COUNTY DEPARTMENT AS THEY ARE RECEIVING MORE VACCINE *** YOU CAN GET INFORMATION ON THEM HERE: https://www.tarrantcounty.com/en/public-health/disease-control---prevention/COVID-19/COVID-19-Vaccine.html

We are asking you to PRE-REGISTER for the Moderna Covid Vaccination at MidCities Pharmacy. As we get more doses, we will email everyone sequentially and let them know to register for the vaccine.

NOTE: We will be signing up those who fit the PHASE 1a and 1b Definition. This includes hospital employees, long term care staff, EMS providers, home health care workers, residents of long term care facilities, outpatient medical staff, community pharmacy staff, emergency response staff, last responders and school nurses.
The PHASE 1b category includes those over 65 years old and patients 18 years and older with chronic conditions.
These will be administered in the our pharmacy at 2000 Precinct Line, Hurst TX 76054.

Please do NOT call the pharmacy. We cannot prioritize anyone, and we are working with everyone sequentially (one by one).
Name of Practice or Your Name (if individual) *
If you are representing a practice or organization, what is your name?
How many people would need to be immunized (include yourself if appropriate)? Enter NUMBERS only *
What is your address & city?
Which category are you in? Phase 1A category (hospital employees, long term care staff, EMS providers, home health care workers, residents of long term care facilities, outpatient medical staff, community pharmacy staff, emergency response staff, last responders and school nurses), PHASE 1B? (65 years or older, of 18 YO+ with chronic medical conditions) *
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). *
Do you currently fill prescriptions at MidCities Pharmacy, have you attended our educational classes, or have we immunized you at our pharmacy before or at our vaccination clinic (Hurst Senior Center / or a home)
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" *
Will this be your first vaccine or second dose of the Covid Vaccine? *
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