Request a COVID-19 Vaccine Appointment

Basic Information

Name*

First Name

Middle Name (optional)

Last Name

Preferred Language*

How did you hear about us?*

How did you hear about us? (Other)*

Are you a current patient of Dedicated Senior Medical Center? *

YES, I am a current patient NO, I am not a current patient

Email*

Cell Phone*

Home Phone

Address Line 1*

Address Line 2

City*

County/Parish*

State*

ZIP Code*

Date of Birth*

Gender*

Race*

Age

Ethnicity - White*

Ethnicity - Black or African American*

Ethnicity - Hispanic or Latino*

Ethnicity - Asian*

Ethnicity - American Indian or Alaska Native*

Ethnicity - Native Hawaiian or Other Pacific Islander*

Ethnicity - Other*