Referral App

(800) 325-1812

(800) 325-1812

Vaccine

Registration

Refer your patient now by uploading their face sheet or submitting a form.

Tue Feb 23 1 pm - 4 pm

Pre-register for the COVID-19 vaccination event now.

Patient Information

First Name

Last Name

Date of Birth

Preferred Language

Priority Group

Patient Mobile Number

Email (optional)

Address

City

State

Zip Code

Have a voucher code?

Your Information

Confirm Referral

Patient Information

First Name:

Last Name:

Date of Birth :

Preferred Language :

Priority Group :

Phone:

Email:

Address:

City:

State:

Zip code:

Voucher code:

Your Information

First Name:

Last Name:

Email:

Phone:

Access Code

Face Sheet

Referral Successfully Received

Thank you

Thank you for your pre-registration with Prism Health Lab. Please note this does not guarantee vaccination. We will review your intake form and send you an email or text message if your pre-registration is approved. If you have any questions or concerns, please email us at info@prismhealthlab.com or call us at (800) 325-1812.

Tue Feb 23 1 pm - 4 pm