Vaccine Request

Through our professional relationship with Wagner Macula and Retina Center, we are able to offer a limited number of vaccine appointments at the Wagner Vaccine clinic. Please complete this form and we will contact you to schedule an appointment. Or, if you prefer, give us a call at 757-605-5244.

Important Information
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 ZIP Code
Phone Number*
Alternate Phone Number*
Email (see footnote below)
Insurance Carrier*
Insurance ID*
Insurance Subscriber's Name*
Social Security Number
Marital Status*
- Single
- Married
Comments
This field is for validation purposes and should be left unchanged.

According to the HIPAA guidelines established by the Department of Health and Human Services, unencrypted email communication is not considered secure, but is permitted if the patient acknowledges and accepts the risks inherent with this form of communication. By submitting this form you authorize Pariser Dermatology to contact you via email regarding an appointment and acknowledge and accept this risk. If you do not wish to leave an e-mail address we will call you to schedule your appointment.

Important Information