COVID-19 VACCINE REGISTRATION
Thank you for inquiring about the Covid-19 vaccine.
To register for a vaccine appointment please complete the form below. Once the form is submitted we will contact you for an appointment.

Please only submit one entry per person.

Innovative Health Care Institute scheduling department will contact you and schedule your appointment.

We have appointments for Pfizer, Moderna, and Johnson and Johnson vaccines

* Pfizer vaccine available for ages 12 and up and newly approved Pfizer for ages 5 years to 11 years.

Remember, once you register our staff will contact you to schedule an appointment. We hold vaccine clinics twice a week. If you have trouble registering, call and leave a message or text us at 706-705-2033.


We are located in East Athens
100 Seagraves Drive, Suite 1
Athens, GA 30605

Visit our website www.IHCI411.com for more vaccine information
or call us at 706-705-2033

Thank you for your patience.
Let's work together to keep our community safe!

Sign in to Google to save your progress. Learn more
Email *
Name (First and Last Legal name) *
Street Address *
City and state and zip code of Residence *
Phone Number *
Date of birth *
MM
/
DD
/
YYYY
Age Range *
Gender *
Race *
Where are you employed? *
Do you have insurance? *
The Georgia Department of Public Health is currently administering the COVID-19 vaccine in Phase 1a+. Please select your category. This will determine your vaccine administration phase in Georgia. *
What Covid-19 vaccine are you requesting? (requested vaccine may not be available ) *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms