COVID-19 Vaccination Request Form
LaPharmacy is administering the COVID-19 vaccines by appointment, based on state eligibility guidelines. To request an appointment, please complete the form below.
Email address *
First Name *
Last Name *
Date of Birth *
Telephone Number *
Special Considerations
Select All That Apply
Over 65 years old
55-64 years old with one or more medical condition defined by the CDC (Cancer, kidney disease, diabetes, etc.)
Emergency Response & Law Enforcement
Healthcare Providers & Health-related Support Personnel
March and April Election Workers
Teacher/Staff working on site at K-12 or Daycare
Non-Emergency Medical Transportation
Clear selection
A copy of your responses will be emailed to the address you provided.
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