Urgent Care Eleven COVID-19 Vaccine Wait List
By submitting this form I confirm that I've provided accurate information and that I meet
the state's eligibility requirements as outlined by the Louisiana Department of Health. You can view the detailed eligibility requirements at https://ldh.la.gov/covidvaccine/
As of February 22, 2021, the Louisiana Department of Health has authorized COVID-19 vaccines to be available to the Phase 1-B, Tier One group. Please select the answer that best describes you. *
First Name *
Last Name *
Date of Birth *
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Phone Number *
Email address *
In the last two weeks, have you tested positive for COVID-19 or are you currently being monitored for COVID-19? *
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