COVID-19 Vaccine Scheduling

1
Please choose which vaccine you wish to receive.* This field is required.You must be 18 or older to receive the Moderna and Janssen (J&J) Vaccine.
Moderna
Janssen (Johnson & Johnson)
2
PLEASE READ!

IMPORTANT INFORMATION REGARDING ADDITIONAL VACCINE DOSES FOR CERTAIN IMMUNOCOMPROMISED INDIVIDUALS

An additional dose of an mRNA COVID-19 vaccine after an initial 2-dose primary mRNA COVID-19 vaccine series should be considered for people with moderate to severe immune compromise due to a medical condition or receipt of immunosuppressive medications or treatments. These conditions and treatments include but are not limited to:

Active treatment for solid tumor and hematologic malignancies

Receipt of solid-organ transplant and taking immunosuppressive therapy

Receipt of CAR-T-cell or hematopoietic stem cell transplant (within 2 years of transplantation or taking immunosuppression therapy)

Moderate or severe primary immunodeficiency (e.g., DiGeorge syndrome, Wiskott-Aldrich syndrome)

Advanced or untreated HIV infection

Active treatment with high-dose corticosteroids (i.e., ≥20mg prednisone or equivalent per day), alkylating agents, antimetabolites, transplant-related immunosuppressive drugs, cancer chemotherapeutic agents classified as severely immunosuppressive, tumor-necrosis (TNF) blockers, and other biologic agents that are immunosuppressive or immunomodulatory.

Factors to consider in assessing the general level of immune competence in a patient include disease severity, duration, clinical stability, complications, comorbidities, and any potentially immune-suppressing treatment.

The Dallas County Health Department recommends speaking with your healthcare provider to determine if you need an additional dose of COVID-19 vaccine.
3
Is this your first, second, or third dose?* This field is required.Janssen (J&J) is only approved for one dose.
First Dose
Second Dose
Third (Booster) Dose
4
I have talked with my healthcare provider and s/he recommends I receive a booster dose of COVID-19 vaccine due to my health condition.* This field is required.
YESNO
5
Will you need an interpreter during your vaccination appointment?
YESNO
6
Preferred language
7
Name* This field is required.
First Name
Last Name
8
Date of Birth* This field is required.
Month
Day
Year
9
Contact Number:* This field is required.
10
E-mailEnter if you wish to receive a confirmation
example@example.com
11
Appointment* This field is required.
Should be Empty:

Save your progress

Save your progress

Your form submission has been saved as a draft.

Save your progress

Your form submission has been saved as a draft.