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
Sign in to Google to save your progress. Learn more
Phone number *
Email *
Street line 1 *
Street line 2
City *
State *
Zip code *
ID Type *
ID Number
First Name *
Last Name *
Birth Date *
Please select age range from the following *
Vaccination Date *
Appointment time *
Dose *
Date of first dose *
Vaccination Physical location (Site) *
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 *
Are you currently Pregnant or breastfeeding? *
Have you received convalescent plasma in the past 3 months? *
Have you received any other Vaccination in the past 14 days? *
Have you been diagnosed with COVID-19 in the past? *
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? *
Have you ever had a severe allergic reaction after receiving a COVID-19 vaccine? *
Have you ever had a severe allergic reaction after receiving another vaccine or another injectable medication? *
Clear form
Never submit passwords through Google Forms.
This form was created inside of dpcareintexas.com. Report Abuse