Appointment Request Form
**Remember that this request does not guarantee an appointment.**
Our volunteers will use the information you provide to book an appointment on your behalf. We reserve the right to only book one appointment per person so please be sure to list all dates you cannot make an appointment in the notes section.
All information is stored in a private encrypted database and held for 31 days, then destroyed.
Once an appointment is made in your name you will receive an email confirmation from the vaccine provider as well as from one of our volunteers with a copy of your confirmation.
We are not responsible for missed appointments, issues at your appointment venue, or what kind of shot you get. We are simply here to help you book an appointment.