COVID-19 Vaccination Verification Form

Memorial Hermann is proud to offer a COVID-19 Vaccine Clinic at Alief ISD (AISD). Vaccinations will be by appointment only and walk-ins will not be accommodated. Please note that, consistent with guidance from the U.S. and Texas Departments of State Health Services, this Clinic is open only to select groups based on the State criteria. Those who do not meet this criteria will not be eligible for vaccination at this particular event.

First Name (as it appears on your photo ID)

Last Name (as it appears on your photo ID)

Birthdate (mm/dd/yyyy)

Please select eligibility criteria to attest to:

Please select the option that best describes your role:

School or child care employee?

By checking this box, I attest that I work in school and/or child care operations as defined by the U.S. Department of Health and Human Services.

Please select the option that best describes your role: