COVID-19 Request Vaccine

Request COVID-19 Vaccine

If you are low-income or uninsured, you may register for your COVID-19 vaccine by completing the form below or by calling 770-503-1369 x301 to leave a message request. After submitting your request either via the form or by phone, we will contact you to schedule your vaccine appointment.

Vaccines will be administered by appointment only.

Request Form for COVID-19 Vaccine Appointment

Name
First Last
Language
Current/Former GNC Patient
- Yes
- No
Date of Birth
MM slash DD slash YYYY
Phone Number
Street Address
Street Address Address Line 2 City State ZIP Code
County of Residence
Age
Employer
Occupation/ Job Role

COVID-19 Request Vaccine

Request COVID-19 Vaccine

Read the Summer 2022 Newsletter!

Sponsorships Available Now for Our 2022 Mardi Gras Celebration!