COVID Vaccine Interest

At this time demand for vaccines is exceeding supply. We will administer vaccines as we receive them. This form helps us prepare by allowing us to track interest and request sufficient allocations. Vaccines will be distributed as we receive them based on interest and public health eligibility. We will contact patients or their designated caregiver to schedule appointments.

Please have your Medicare Card (with your Medicare Number) and/or insurance card available.

COVID-19 VACCINE INTEREST FORM 1.21.21

Patient Info
Patient First Name*
Patient Last Name*
Patient Date of Birth*
Patient Phone Number (Primary)*
XXX-XXX-XXXX
Patient Phone Number (Alternate)
XXX-XXX-XXXX
Patient Street Address
Patient City*
Patient Zip*
Physician Info
Primary Care Physician*
- Cullen Ocmond
- Jerry Poche
- Randal Poche
- Jarelle Scott
Contact Info
Best person to call when vaccines are available?
- Patient
If you are a patient filling out this form and want to be contacted directly choose patient and leave fields below empty. If you are not the patient or want us to contact a caregiver/family member, fill out the fields below.
Contact First Name
Contact Last Name
Contact Phone Number
XXX-XXX-XXXX
Relationship to Patient
We will contact you.
We will distribute vaccines as we receive them based on public health eligibility and a priority assessment. We will contact patients or their designated caregiver to schedule appointments.

COVID Vaccine Interest

COVID-19 VACCINE INTEREST FORM 1.21.21

Patient Info

Physician Info

Contact Info

We will contact you.