Abilene Taylor County Public Health District
Individuals that meet phase 1B criteria can complete the following google form and submit. Only submit one form per person. Multiple submissions and calls will cause further delays in scheduling. Additionally, if you do not qualify for Phase 1A-1B distribution, you will not be placed on a waiting list nor will you be contacted. We receive many requests and can only respond to those meeting state guidelines.
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Enter patient's LAST name *
Enter patient's FIRST name *
Enter patient's Date of Birth *
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Enter patient's age
Enter patient's address *
Enter patient's phone number *
Enter patient's email address (optional)
Did the Patient have a previous COVID infection? *
Is the Patient pregnant? *
Are you a healthcare worker? If yes, please identify your employer below:
Does the patient meet the following requirements: At least 16 years of age and older with at least one chronic medical condition that puts them at increased risk for severe illness from the virus that causes COVID-19, such as but not limited to: Cancer, 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, or Type 2 diabetes mellitus.
Have you received your 1st dose? If yes, please select what brand you received.
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Enter any comments you may have *
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