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 *
MM
/
DD
/
YYYY
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
Pregnant
Non-Emergency Medical Transportation
Clear selection
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy