Covid-19 Vaccine Wait List Contact Information

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*IMPORTANT INFORMATION**
PCHS does not have vaccines at this time and we do not know when we will receive more. We are gathering information so that we will have patient information ready.

Tier 1a (Healthcare) and Tier 1b organizations (front line workers such as fire fighters, law enforcement and teachers) should not fill out this form. A head contact with the organization must email us at covidvaccine@pchsmedclinic.org.

Individuals who are 65 or older, or 18 years of age or older AND have medical conditions that put you at high risk, such as but not limited to:
• Chronic kidney disease
• COPD (chronic obstructive pulmonary disease)
• Heart conditions, such as heart failure, coronary artery disease or cardiomyopathies
• Solid organ transplantation
• Obesity and severe obesity (body mass index of 30 kg/m2 or higher)
• Pregnancy
• Sickle cell disease
• Type 2 diabetes mellitus

If would like to be on a Covid Vaccine waiting list please fill out this form.

The general public is welcome to fill out this form to be on a wait list, however PCHS prioritizes vaccine recipients based on the State of Texas Guidelines. For more information visit the following website: https://www.dshs.state.tx.us/coronavirus/immunize/vaccine.aspx

PLEASE DO NOT CALL OUR CLINICS INQUIRING ABOUT THE COVID-19 VACCINE.

PCHS Alpine-1605 N Ft Davis Hwy ~ PCHS Marfa-406 S summer Street ~ Presidio 1501 N Erma Ave

First Name *

Last Name *

Date of Birth *

YYYY

Phone number *

E-mail Address

Established PCHS Patient (seen at our offices within the last year) *

Yes

What criteria do you meet to receive this vaccine? https://dshs.texas.gov/coronavirus/immunize/vaccine/EVAP-Phase1A.pdf or https://dshs.texas.gov/coronavirus/immunize/vaccine/EVAP-Phase1B.pdf *

Tier 1a (Healthcare) Do not fill out this form. This must be organized through covidvaccine@pchsmedclinic.org

Tier 1b (65+)

Tier 1b (18 years of age or older AND have medical conditions that put you at high risk)

General Public

Preferred location to receive vaccine. *

Alpine, Texas

Presidio, Texas

Marfa, Texas

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