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Appointment Request

1
Appointment
2
Demographics
3
Insurance
4
Documents
1
Appointment
2
Demographics
3
Insurance
4
Documents

To request an appointment, please select your preferred day of week and time frame. If an appointment is available that meets the criteria provided, you will receive a text confirmation that your appointment is scheduled.

At this time, we are not offering after-hours appointment. Get your Flu shot along with your COVID-19 Vaccine appointment.

Appointment

You should be a healthcare worker or 65+ years old to request a COVID-19 vaccine appointment at this time.
Yes
No
Yes
No
Pfizer
Moderna

Demographics

Decline to Answer
Decline to Answer
Home
Work
Cell
Yes
No
Yes
No

Insurance

Self
Not insured
Self

Documents


Front Image (Supported Formats: (.pdf,.png,.jpg); Max-Size: 3MB)
Back Image (Supported Formats (.pdf,.png,.jpg); Max-Size: 3MB)
Declaration
I understand that by submitting this appointment request form I am only requesting an appointment and a Clinica Sierra Vista representative will call/text to discuss availability.