Request for Vaccine Appointment

Please complete the form below to be placed on our waiting list for the COVID-19 vaccine. You will be required to bring an ID, and all information below must match your ID or you will not receive a vaccine. A representative will call you when a dose is available and schedule your appointment. Please be patient until you receive a call. We are administering vaccines as soon as we receive them.

Date of Birth

Email (not required if disclosure not wanted)

Address Autocomplete

Address or Location

Home Phone

Mobile Phone

Communication Preference:

SMS

Both

neither

If you do not speak English, in what language do you communicate?

Hearing loss and need accommodations for effective communication?

If yes, type of accommodation?

ASL Interpreter

Personal amplification device

Writing back and forth

Clear Mask

Race

American Indian/Alaska Native

Asian

Black or African American

White

Other

Ethnicity

Hispanic or Latino

Not Hispanic or Latino

Are you an essential frontline worker (Police, Food Processing, Teacher, etc.)

Do you reside in a long-term care facility or assisted care facility?

Name of Facility:

Are you a member of a state or federal recognized tribe?

Name of Tribe:

How many conditions know to increase risk of illness with Covid-19 do you have?

I certify that I am: (a) at least 18 years of age (b) the parent or legal guardian of the minor patient; or (c) the legal guardian of the patient. Further, I hereby give my consent to the licensed healthcare provider administering the vaccine, as applicable (each an “applicable Provider”), to share my personal, demographic and health condition information in order to provide me with vaccination services for the COVID-19 vaccine. I understand that the health data shared within this questionnaire will be used to determine my eligibility for receiving the COVID-19 vaccination and further determine timing of when the vaccine will be made available to me.

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.