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 vaccineColumn16CompletedIf other vaccine, which one are you requesting?Do you have health insurance? If so, which plan?Registration formInsurance Member ID
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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
Susan
Mitchell01/12/22The person mentioned above5614 CheyenneGarland972-849-6730
15
Matthew
Mitchell01/12/22The person mentioned above5614 CheyenneGarland972-849-6730
16
Rhonda
Mtchell01/12/22The person mentioned above5614 CheyenneGarland972-849-6730
17
Jettie
Williams01/12/22The Caregiver of this person618 AltoGarland972-271-7887
18
Steven
Langrehr01/12/22The Caregiver of this person3633 Plaza ParkGarland469-596-4750
19
Wilma
Walton01/12/22The Caregiver of this person1614 MosswoodGarland214-715-1850
20
Margaret
Keeton01/12/22The Caregiver of this person1614 MosswoodGarland214-715-1850
21
Shiela
White01/12/22The person mentioned above223 GlenfieldGarland972-271-9172
22
Helen
Williams01/12/22The person mentioned above310 Beltline4106Garland214-336-7252
23
Ida Bell
White01/12/22The person mentioned above604 Ford St.Garland469-223-3019
24
Michael
White01/12/22The person mentioned above705 W. Ave. B1401Garland214-900-3724
25
Maria
Aguirre01/12/22The person mentioned above1513 Sam HoustonGarland214-622-7593
26
Jerome
Moore01/12/22The Caregiver of this person9805 PinehurstRowlett214-476-9693
27
Santa Anita
Neubert01/12/22The Caregiver of this person1679 W. Campbell6301Garland409-750-1456
28
Rodney
Neubert01/12/22The Caregiver of this person1679 W. Campbell6301Garland409-750-1456
29
Robert
Otey01/12/22The Caregiver of this person2949 Big BenGarland214-683-7023
30
Amy
Otey01/12/22The Caregiver of this person2949 Big BenGarland214-683-7023
31
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
32
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
33
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
34
James
Mcdaniel01/24/22The 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
35
Oralia
Baker01/27/22The person mentioned above2902 Willow RidgeGarland972-754-9252
36
Helen
Baker01/27/22The person mentioned above2902 Willow RidgeGarland972-754-9252
37
Dana
Nuckols01/27/22The person mentioned above1731 Novel Cir.Garland972-480-7769
38
Roxanne
Nuckols01/27/22The person mentioned above
`		1731 Novel Cir.Garland972-480-7769
39
James
McDaniel01/27/22The person mentioned above608 WentworthRichardson214-534-4423
40
Joseph
Fishpaw01/27/22The person mentioned above4221 PrinctonGarland469-766-1951
41
Geneva
Chavez01/27/22The person mentioned above2814 WimbledonAGarland214-918-2667
42
Betty
Skinner02/10/22The person mentioned above1211 RavinaGarland972-278-2576
43
Michael
White02/10/22The person mentioned above705 W. Ave. BGarland214-900-3724
44
Shiela
White02/10/22The person mentioned above223 GlenfieldGarland972-271-9127
45
Judy
Barron02/10/22The person mentioned above611 Parker Cir.GarlandN/A
46
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
47
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
48
Barbara
Chick02/22/22The 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
49
Geneva
Lee02/22/22The person mentioned above5012 BurlingameGarland972-374-6872
50
Lilly
Beverly02/22/22The person mentioned above3301 KenwoodGarland972-475-1997
51
Rose
Purrin02/22/22The person mentioned above1420 McCrearyWylie214-552-0313
52
Joy
Pilkinton02/22/22The person mentioned above1113 MarionGarland972-276-0929
53
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
54
Anh K.
Dang04/07/22The person mentioned above4009 Fletcher Dr.Garland972-469-0982
55
Rose
Ramming04/07/22The person mentioned above1122 Bowie St.Garland469-829-5575
56
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
57
Shann
Stahl05/20/22The Caregiver of this person222 Xavier Dr.Garland972-840-2759
58
TEst
TEst05/26/22The person mentioned above123 Carver1Garland21412314569bsolorzano@garlandtx.govNo1No1. Moderna COVID-19 Vaccine Initial Series for individuals 18 years old and older – Two doses administered 28 days apart
59
SANTA ANITA
NEUBERT07/19/22The Caregiver of this person1679 W CAMPBELL RDAPT 6301GARLAND4097501456rmneubs@yahoo.comYES1NO3. 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
60
Guadalupe
Garcia07/21/22The person mentioned above2102 Pueblo DrN/aGarland4694785767Pita.garcia03@gmail.comMy car has been repossessed, needing help with transportation2No5. Pfizer COVID-19 Vaccine Initial Series for children ages 5-11 years old – Two doses 21 days apart
61
Julian
Castellanos09/14/22The Caregiver of this person4018 Glenrose DriveN/AGarland2144177689johnrcastellanos@yahoo.comYes, He has Mobility Issues2Yes. His Daughter, Patricia C. Stansfield2. Moderna COVID-19 Bivalent Vaccine Booster Dose – Administered at least 6 months after completing the initial series
7. Influenza (Flu) Vaccine (Inactivated or Recombinant) - Individual 6 months and older
62
John
Castellanos09/14/22The person mentioned above4018 Glenrose DriveN/AGarland2144177689johnrcastellanos@yahoo.comI am a Caregiver for Julian H. Castellanos, my 84 Year Old Father2No2. Moderna COVID-19 Bivalent Vaccine Booster Dose – Administered at least 6 months after completing the initial series
7. Influenza (Flu) Vaccine (Inactivated or Recombinant) - Individual 6 months and older
63
Rose
Ramming10/04/22The person mentioned above1122 Bowie St1122Garland4698295575mramming@verizon.netNoNoneNoModerna COVID-19 Vaccine Additional Dose --28 days after the second dose2. Moderna COVID-19 Bivalent Vaccine Booster Dose – Administered at least 6 months after completing the initial series
64
Roger
Smith11/09/22The Caregiver of this person7513 Oakhurst TrailN/AGarland214-532-2150carolmcdsmith@gmail.comYes1Yes2. Moderna COVID-19 Bivalent Vaccine Booster Dose – Administered at least 6 months after completing the initial seriesWould also like for him to get the Flu shotYes. Medicare and Medigap with Blue Cross Shield of Texashttps://www.garlandtx.gov/3530/Forms4Y22-Y75-CQ13 - Medicare. ZGM860902166 - Blue Cross Blue Shield of Texas
65
RICHARD
RAMIZEZ11/14/22The person mentioned above1710 TOBIN TRAIL2GARLAND TX 750432144783669BETT.CHRISTHOUSE@GMAIL.COMWHEELCHAIR2YES BUT ABLE TO MAKE DECISION NOW7. Influenza (Flu) Vaccine (Inactivated or Recombinant) - Individual 6 months and olderYES, HUMANAhttps://www.garlandtx.gov/3530/FormsH70390403
66
HERLINDA
RAMIREZ11/14/22The person mentioned above1710 TOBIN TRAIL2GARLAND TX 750432144783669BETT.CHRISTHOUSE@GMAIL.COMWALKER AND DEBILITY2YES BUT ABLE TO MAKE DECISION NOW7. Influenza (Flu) Vaccine (Inactivated or Recombinant) - Individual 6 months and olderYES, HUMANAhttps://www.garlandtx.gov/3530/FormsH41591345
67
Sharon
Beall11/16/22The Caregiver of this person1418 Stoneboro LaneNONERichardson4692431449ltgov37@msn.comAltzimer patientoneyes7. Influenza (Flu) Vaccine (Inactivated or Recombinant) - Individual 6 months and olderMedicarehttps://www.garlandtx.gov/3530/Forms5MR7-CW4-MU76
68
69
Joseph
Fishpaw12/20/22Other4221 Princeton DrivehouseGarland469-766-1951cifishpa@gmail.comweight is over 6001noModerna COVID-19 Vaccine Initial Series for individuals 18 years old and older2. Moderna COVID-19 Bivalent Vaccine Booster Dose – Administered at least 6 months after completing the initial seriesFluemarket Placehttps://www.garlandtx.gov/3530/FormsUnknown
70
Japalene (Jackie)
Peterson01/04/23The person mentioned above1213 Alamo LaneNAGarland972-276-3524Cbaker429@gmail.comYes0YesTB testNeed TB testYes, Medicarehttps://www.garlandtx.gov/3530/Forms9JN4-JD9-CV95