MIDCITIES Covid Vaccine Pre-Registration
MIDCITIES PHARMACY at 2000 Precinct Line Rd, Ste 102, Hurst, Texas 76054.

Please NOTE - this is a form that we used for pre-registration in December 2020 to March 2021.  AS OF AUG 31, 2021, we are going to use this TEMPORARILY FOR JOHNSON and JOHNSON pre-registration (we only have a limited amount left and all of it is already booked). We are having cancellations or no shows and we will use your info to reach out to you.

IMPORTANT NOTE: If you have no insurance, our policy is that you MUST provide either your SS# or Texas Drive License card (or TX ID card).  As of August 1, we are unable to provide vaccines to people who are in the US on a visitor visa - sorry.

NOTE: These will be administered in the our pharmacy at 2000 Precinct Line, Hurst TX 76054.
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Your Name *
If you are representing a practice or organization, please indicate which one? If only yourself, then leave blank.
To make sure that you are not a robot, write the word "one" on this field. Anything else will reject your entry. *
What is your address, city and ZIP? If you are close to us, we may use you as a backup on short notice.
Which category are you in?   *
What is the best email for you? Email will be sent to everyone as it comes available. MAKE SURE THIS IS CORRECT. *
What is a direct contact number for you (we will not be calling initially due to volumes requested). MOBILE number is BEST. Save our pharmacy number 817-605-3500 on your mobile phone *
If this is Moderna, do you prefer your second dose on a FRIDAY (to avoid side effects)
On your prescription insurance card, write ONLY the BIN and PCN number here. Don't write the ID or GROUP. If you don't have prescription insurance, write "NO INS". Do NOT write your personal information.  You MUST provide your SS# and present your Texas ID card or Driver License if you do not have insurance. All insurances pay for the vaccine and it is zero out of pocket costs. *
Will this be your first vaccine or second dose of the Covid Vaccine? *
If second vaccine is needed, WHEN and WHERE did you get your first one?
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