COVID-19 Queue - Mobile Vaccine Sign-up

Mobile COVID-19 Vaccination Clinic Sign-up

COVID-19 vaccines are available to all Arkansans age 5 and over.

* Required

Patient Information

First Name *

Last Name *

Date of Birth *

Street Address Line 1 *

Street Address Line 2

City *

State *

Postal/Zip Code *

Phone *

Cell Phone

Marital Status *

Sex *

Race *

Social Security Number

Employer

I don't have one

Occupation

MyChart Sign-up

Do you want to sign-up for MyChart? *

Yes

MyChart Contact Preference

If Patient is a minor:

Guardian First Name

Guardian Last Name

Guardian Relationship to patient

Guardian address different from above

Guardian Street Address Line 1 *

Guardian Street Address Line 2

Guardian City *

Guardian State *

Guardian Postal/Zip Code *

Emergency Contact Information

Emergency Contact First Name *

Emergency Contact Last Name *

Emergency Contact Phone *

Emergency Contact Relationship to patient *

Spouse Date of Birth *

Insurance Information

Uninsured

Primary Insurance

Medicare/Medicaid

Primary Insured Name *

Primary Insurance Company *

Primary Insured relationship to patient *

Primary Group Id *

Primary Policy Number *

Primary Insurance Phone Number *

Secondary Insurance

Secondary Insured Name

Secondary Insurance Company

Secondary Insured relationship to patient

Secondary Group Id

Secondary Policy Number

Secondary Insurance Phone Number

Mobile Location *