COVID-19 Immunization Waitlist
Please fill out this form to be placed on the COVID-19 immunization waitlist for when it comes available. Priority will be based on guidance from the CDC and the Department of Public Health.
Please fill out and submit this form.
A new submission needs to be completed for each individual family member. Currently the vaccine we have on hand is only approved for ages 18 and older. Please make sure to fill out the entire form until you get to the last page that says "Thank You!"
Date of Birth
Age - days
Patient Phone Number
Cell Phone preferred but not required
Street Address Line 2
State / Province
Postal / Zip Code
Are you one of the following?
Please select the one that best fits you.
Age 75 and Older
Frontline Essential Worker (first responder, education, grocery, meat processing, manufacturing, postal service)
Age 65 to 74
Age 18 to 64 with high risk medical condition
CDC: Healthcare Personnel
CDC: Frontline Essential Worker
CDC: High Risk Medical Conditions
Should be Empty:
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