SLIM:: Appointments

Register for your covid-19 vaccine today

We are offering Janssen (Johnson & Johnson) COVID-19 Vaccine based on eligibility criteria as determined by the Texas Department of State Health Services. This vaccine is administered as a single dose.

Gender

Male

Female

Other

I have Health Insurance

I do not have Health Insurance

Screening for Vaccine Eligibility :

You have allergies to any material in the COVID-19 vaccine or have had an anaphylactic reaction in the past, you should not get the vaccine. Please refer to the Emergency Use Authorization Fact Sheet for ingredients of the vaccine.

By signing below, I attest that I belong to one of the below categories of people as per CDC COVID-19 vaccination guidelines.

Phase 1A: Front-line healthcare workers and residents at long-term care facilities
Phase 1B: People 65+ or people 16+ with a health condition that increases risk of severe COVID-19 illness, including but not limited to: Cancer, Chronic kidney disease, COPD (chronic obstructive pulmonary disease), Down Syndrome, Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies, Organ transplantation, Obesity Pregnancy, Sickle cell disease, Type 2 diabetes
School and Child Care Personnel (as per the new federal directive)

Have you been vaccinated with any brand of COVID-19 vaccine before?

Yes

If you answered yes to the above question, you do not qualify for the vaccination at this time.

Consent:

I have read or had explained to me the Emergency Use Authorization Fact Sheet or a Vaccine Information Statement for the Janssen COVID-19 vaccine and understand the risks and benefits. I have received the same in electronic or print form.

I GIVE CONSENT to SLIM Healthcare Associates, PLLC and its staff for the above-named person to be administered this vaccine. (this consent form is not signed, then this person will not be vaccinated) .

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.