DPC in Texas Vaccination Appointment

Must be 16 or Older

Main Office:
Fort Worth: 7311 S Hulen St, Fort Worth, TX 76133
Contact:1 (817) 881-5010

Phone number *

Email *

Street line 1 *

Street line 2

City *

State *

Zip code *

ID Type *

ID Number

First Name *

Last Name *

Birth Date *

YYYY

SEX *

RACE *

Please select age range from the following *

I am an adult (18+)

I am under 18

Vaccination Date *

YYYY

Appointment time *

Time

Dose *

First Dose

Second Dose

Date of first dose *

YYYY

Vaccination Physical location (Site) *

Main Site: 7311 S Hulen St, Fort Worth, TX 76133

Church: 201 Sandy Ln, Fort Worth, TX 76120

Arlington: 1115 W Arkansas Ln Suite B, Arlington TX 76013

Dallas: 805 S Sherman St, Richardson TX 75081

4021 Conflans Rd, Irving, Texas 75062

Other:

Please Read

If you have severe reactions with immunizations, please consult with your physician prior to registering for COVID-19 vaccination.

COVID-19 Vaccine is currently being distributed in a phased approach based on the recommendation of the Department of State Health Services and the Expert Vaccine Allocation Panel. This registration form will ask qualification questions and only allow registration if you meet the criteria.

According to State requirements, all adults that are eligible may register

PRIOR TO SUBMITING, please read the Emergency Use Authorization Fact Sheet for the Moderna COVID-19 vaccine on our website (https://www.dpcareintexas.com/home) or directly from the CDC website (https://www.cdc.gov/vaccines/covid-19/eua/index.html). You must be 16 or older to receive the Moderna vaccine.

By proceeding and giving consent, you acknowledge your understanding of the risk and benefits. IF YOU DO NOT CONSENT, YOU MUST NOT SUBMIT.

By checking 'I CONSENT' to the following question, you GIVE CONSENT to the Direct Primary Care in Texas to receive a COVID-19 vaccine.

I consent to the above *

I consent

I Do Not Consent

Are you currently Pregnant or breastfeeding? *

Yes

Have you received convalescent plasma in the past 3 months? *

Yes

Have you received any other Vaccination in the past 14 days? *

Yes

Have you been diagnosed with COVID-19 in the past? *

Yes

Have you ever had a severe allergic reaction (e.g. anaphylaxis) to something? For example, a reaction for which you were treated with epinephrine or EpiPen, or for which you had to go to the hospital? *

Yes

Have you ever had a severe allergic reaction after receiving a COVID-19 vaccine? *

Yes

I have not received the COVID-19 vaccine

Have you ever had a severe allergic reaction after receiving another vaccine or another injectable medication? *

Yes

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