Book Vaccination Online

Covid-19 vaccination appointment

PLEASE READ:

Please fill out the below information as accurately as possible. You will be entering information for who will be the primary contact should we need to reach someone. Secondly, you will be entering the information on who will receive the vaccine. One person can schedule appointments for numerous people but each appointment should be unique to that recipient.

*required field

Point of Contact Information

Please enter the information on who we should contact regarding the appointment. If you will be the one receiving the vaccination, you can check the checkbox under "Contact First Name" to copy this information to the applicable vaccine recipient fields.

Contact First Name*

Contact Last Name*

Contact Email Address:*

Contact Phone Number*

I will be the one reciving the vaccine.

Booking Confirmed!

Congratulations! Your appointment has been confirmed! Your confirmation information is:

Please check your Email for additional appointment details.

Vaccine Recipient Information

This is where you enter information on who will be receiving the vaccine and select an available appointment slot. You must also check the boxes at the bottom indicating that you are either a resident of Arkansas or employed in Arkansas and will not be receiving any other vaccinations 14 days prior to the selected appointment date.

Recipient Legal First Name*

Recipient Legal Last Name*

Recipient Phone Number*

Date of Birth:*

I certify the vaccine recipient is a resident of Arkansas or employed in Arkansas and eligible for vaccination.More info on vaccine eligibility

Please select an appointment:

Recipient will not have had ANY vaccinatons in the 14 days prior to the selected appointment date.

Some information is missing or incorrect.