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Request a COVID-19 Vaccine Appointment

Securing and distributing COVID-19 vaccines is a top priority. COVID-19 vaccinations are critical to help prevent the further spread of the virus.

SUBMIT YOUR APPOINTMENT REQUEST BELOW

[DEDICATED-PROD] COVID Vaccine Appointment Request Form

Basic Information

Name*
Are you a current patient of Dedicated Senior Medical Center? *

Contact Information

Demographics

Date of Birth*

Appointment Request Details

Preferred Day of Week*
Preferred Time of Day*
Disclaimer
Disclaimer

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