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
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.
Person aged 65 or older
Dialysis provider or patients
Ambulatory and outpatient provider or staff
Professional home care provider (hospice worker), home care recipient
American Sign Language (ASL) or foreign language interpreter, Support Service Providers (SSPs)
Health-related support personnel
School of allied health student, resident or staff
Law enforcement or other first repsonder
Louisiana Unified Command Group
State or local essential COVID emergency response personnel
Teacher or any other support staff working on site in K-12 or daycare
Individual aged 55-64 with at least of the conditions listed by the CDC
Election staff for March and April elections
None of the above
Date of Birth
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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