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.
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Email *
Are you currently eligible to receive the COVID-19 Vaccine? (View eligibility requirements here: *
If you are eligible to receive the COVID-19 vaccine, please state which of the criteria you meet (for example "cancer," "current or former smoker," "law enforcement" or "teacher"). View eligibility requirements here:
First Name *
Last Name *
Date of Birth *
Telephone Number *
A copy of your responses will be emailed to the address you provided.
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