COVID-19 Vaccination Verification Form En Español In English Memorial Hermann is proud to announce a COVID-19 Vaccination Clinic. First Name (if registering for a minor, enter the child's name) Last Name (if registering for a minor, enter the child's name) Email Primary Phone Date of Birth (mm/dd/yyyy) Please select the option that best applies to you: -- Select -- I attest that I am 18 years of age or older and meet the CDC criteria to receive a COVID-19 vaccine. I attest that I am the parent or guardian of a minor that meets the CDC criteria to receive a COVID-19 vaccine.