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COVID-19 Vaccination Request Form
LaPharmacy is administering the COVID-19 vaccines by appointment, based on state eligibility guidelines. To request an appointment, please complete the form below.
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Email
*
Your email
Are you currently eligible to receive the COVID-19 Vaccine? (View eligibility requirements here:
https://ldh.la.gov/index.cfm/page/4137
)
*
Yes
No
If you are eligible to receive the COVID-19 vaccine, please state which of the criteria you meet (for example "cancer," "current or former smoker," "law enforcement" or "teacher"). View eligibility requirements here:
https://ldh.la.gov/index.cfm/page/4137
Your answer
First Name
*
Your answer
Last Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Telephone Number
*
Your answer
A copy of your responses will be emailed to the address you provided.
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