Home Vaccine Request
First NameLast NameForm Date FieldI amStreet AddressUnit/Apartment NumberCityPhone NumberEmail addressAmbulatoryDoes the individual have a Medical Power of AttornOthers in householdPower of attorneyDateWhich vaccineColumn16Completed
 Collaboration powered by Smartsheet   |   Report Abuse
1
Sam
A12022021The Medical Power of Attorney206 Carver StGarland972-205-3361sarroyo@garlandtx.govNoNoNoCOVIDTEST ENTRY
2
Jonas
Salk12/09/21The person mentioned above1500 Polio LaneNAGarland8675309atassin@garlandtx.govNo19No4. Pfizer COVID-19 Vaccine Initial Series for individuals 12 years old and older – Two doses 21 days apart
3
Linsey
Shaeffer12/14/21The person mentioned above1909 Royal Crest Drive.Garland2146818314Linsey.Shaeffer@gmail.comYes1NoModerna COVID-19 Vaccine Initial Series for individuals 18 years old and older1. Moderna COVID-19 Vaccine Initial Series for individuals 18 years old and older – Two doses administered 28 days apartno, pt went elsewhere
4
Michael
White12/27/21The person mentioned above705 W Ave B 1401Apt 1401Garland12149003724Michael rwhite42@gmail.comyes1noModerna COVID-19 Vaccine Initial Series for individuals 18 years old and older1. Moderna COVID-19 Vaccine Initial Series for individuals 18 years old and older – Two doses administered 28 days apartyes
5
Robert
Otey12/27/21The person mentioned above2949 Big Ben Lanen/aGarland2146837023Trevisotey@att.netRecent heart attack & compromised breathing1NoModerna COVID-19 Vaccine Additional Dose --28 days after the second dose
Moderna COVID-19 Vaccine Initial Series for individuals 18 years old and older
3. Moderna COVID-19 Vaccine Booster Dose – Administered at least 6 months after completing the initial series or 2 months for those who received an initial dose of Janssenyes
6
Dina
Ahmed12/28/21Other
The Caregiver of this person
3030 Kingswood Dr.N/AGarland2148751903hannanjahmed@gmail.comDisabled; autism and uses wheelchair0No7. Pfizer COVID-19 Vaccine Booster Dose – Administered at least 6 months after completing the initial series or 2 months for those who received an initial dose of Janssenno, pt will c/b to r/s
7
Jerome
Moore12/28/21The Medical Power of Attorney9805 Pinehurst DrN/aRowlett2144769693jmoore8624@gmail.comWheelchair: quadriplegic1 (2 total booster shots)Yes3. Moderna COVID-19 Vaccine Booster Dose – Administered at least 6 months after completing the initial series or 2 months for those who received an initial dose of Janssenyes
8
SANTA ANITA
NEUBERT12/28/21The Caregiver of this person1679 W. CAMPBELL RD#6301GARLAND4097501456rmneubs@yahoo.comYES1NOModerna COVID-19 Vaccine Additional Dose --28 days after the second dose3. Moderna COVID-19 Vaccine Booster Dose – Administered at least 6 months after completing the initial series or 2 months for those who received an initial dose of Janssenyes
9
Steven
Langrehr12/30/20The person mentioned above3633 plaza park drive3633Garland4695964750slangrehr@mail.comCOPD3No3. Moderna COVID-19 Vaccine Booster Dose – Administered at least 6 months after completing the initial series or 2 months for those who received an initial dose of Janssenyes
10
Ida Bell
White01/05/22The Caregiver of this person604 Ford StreetN/AGarland4692233019bmilo@hallpark.comShe is 99 so she has to have a walker and assistance1No but we are working on that.7. Pfizer COVID-19 Vaccine Booster Dose – Administered at least 6 months after completing the initial series or 2 months for those who received an initial dose of Janssenyes
11
Helen
Williams01/28/21The Caregiver of this person310 Beltline Rd4106Garland2143367252rogerbw1@gmail.comyes, she is 98 and suffered a heart attack in the past six month and also has onset of dementia. She needs the booster, received the first two Madera shot at the Garland drive through event in FebruaryNoNOModerna COVID-19 Vaccine Initial Series for individuals 18 years old and older3. Moderna COVID-19 Vaccine Booster Dose – Administered at least 6 months after completing the initial series or 2 months for those who received an initial dose of Janssen3/112021yes
12
Walter
White01/06/22Other223 Glenfield DriveN/AGarland9722719172bmilo@hallpark.comCane and he has seizures2No4. Pfizer COVID-19 Vaccine Initial Series for individuals 12 years old and older – Two doses 21 days apart
13
Sara
Hochstein01/10/22The person mentioned above2314 Highmont Dr-Garland214-885-4386David _Hochstein36@yahoo.comno1noModerna COVID-19 Vaccine Additional Dose --28 days after the second dose3. Moderna COVID-19 Vaccine Booster Dose – Administered at least 6 months after completing the initial series or 2 months for those who received an initial dose of Janssen
14
John
Letcher01/10/22The person mentioned above4126 Windsor DrN/AGarland2146428518jglwow@gmail.comNo1Yes1. Moderna COVID-19 Vaccine Initial Series for individuals 18 years old and older – Two doses administered 28 days apartno, left multiple voicemails
15
Geneva
E chavez01/14/22The person mentioned above2814 Wimbledon CourtUnit AGarland2149182667payasita4324312@gmail.comHeart failureNone just meNopfizer COVID-196. Pfizer COVID-19 Vaccine Additional Dose – 28 days after the second dosePfizer COVID-19Yes
16
Kendall
Campbell01/19/22The Caregiver of this person709 Creekside DriveNo apartmentMesquite972-658-1596brittkam7@aol.comYesNoneParents have guardianship over Kendall Campbell4. Pfizer COVID-19 Vaccine Initial Series for individuals 12 years old and older – Two doses 21 days apartno, pt went elsewhere
17
James
Mcdaniel01242022The person mentioned above608 Wentworth drNoneRichardson2145344423Jamj2588@gmail.comYes0Yes7. Pfizer COVID-19 Vaccine Booster Dose – Administered at least 6 months after completing the initial series or 2 months for those who received an initial dose of Janssenyes
18
Thomas
Chick02/12/22The Caregiver of this person114 S BULLOCK DRN/aGarland9722762524tomchick70@gmail.comYesNoYes7. Pfizer COVID-19 Vaccine Booster Dose – Administered at least 6 months after completing the initial series or 2 months for those who received an initial dose of Janssen
19
Barbara
Chick02/12/22The Caregiver of this person114 S BULLOCK DRn/aGARLAND19722762524barbaratc39@gmail.comyes0yes7. Pfizer COVID-19 Vaccine Booster Dose – Administered at least 6 months after completing the initial series or 2 months for those who received an initial dose of Janssen
20
Barbara
Chick02/17/22The Caregiver of this person114 S BULLOCK DRn/aGARLAND9722762524barbaratc39@gmail.comyes0yes7. Pfizer COVID-19 Vaccine Booster Dose – Administered at least 6 months after completing the initial series or 2 months for those who received an initial dose of Janssen
21
Kim Mai
Nguyen04/01/22The person mentioned above4009 Fletcher Drn/aGarland972-496-0982xmai_nguyenx@yahoo.comYes1 (total 2: for my husband & me)No7. Pfizer COVID-19 Vaccine Booster Dose – Administered at least 6 months after completing the initial series or 2 months for those who received an initial dose of Janssen
22
Donald and Janie
Smith04/11/22The Caregiver of this person1222 Wagonwheel Rd.single family homeGarland214-215-8549gregsmithdds@aol.comboth patients on walkers..very limited mobilityjust two..husband and wifeyesModerna COVID-19 Vaccine Additional Dose --28 days after the second dose
Moderna COVID-19 Vaccine Initial Series for individuals 18 years old and older
4. Pfizer COVID-19 Vaccine Initial Series for individuals 12 years old and older – Two doses 21 days apartwhen needed