Vaccine Clinic Requests from DPS Nurses
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
School Name
In-School Immunization Program or Community Clinic?
In-School Immunization
Community Clinic
Preferred Clinic Date #1 and Time
Preferred Clinic Date #2 and Time
Preferred Clinic Date #3 and Time
Submit
Should be Empty: