Covid-19 vaccination appointment
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.
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.
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.
Date of Birth:*