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County of Wayne

224 E Walnut Street, Goldsboro, NC, 27530, US

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.

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    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.

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