COVID-19 Vaccination Appointment Request

COVID-19 Vaccination Appointment Request
Lakeland Community Hospital was pleased to learn from the Alabama Department of Public Health that the COVID-19 vaccination program will be expanded to include people 16 years and older effective April 5, 2021. If you would like to join the waiting list for an appointment at our vaccination clinic, please complete the form below. We will contact you directly when we have an appointment available. Appointments are made based on the availability of vaccine. According the the Alabama Department of Public Health, "COVID-19 vaccine remains limited, continued patience is urged as demand is great."

Completing this form is not a guarantee of an appointment. Information about additional vaccination locations is available on the ADPH website.

We are excited to reach this next phase of the vaccination program.
Please complete the request form below to be put on the waiting list.

We will contact you by phone when we have an appointment available. Completing this form is NOT a guarantee that you will receive an appointment as we have a limited supply of vaccine.
Today's Date *

Month Day Year
Date
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Phone Number *
Please enter a valid phone number.
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
County of Residence
County
Email Address (If you have one)
example@example.com
I have previously received a COVID-19 vaccine. *

Yes No
I have been tested for COVID-19 in the past two weeks. *

Yes No
I have received monoclonal antibody infusion in the last 90 days due to COVID-19. *

Yes No
You may also print the form by clicking here and email a scanned copy to gerita.rye@lch.care.
COVID-19 Vaccination Appointment Request
Should be Empty:

COVID-19 Vaccination Appointment Request

Please complete the request form below to be put on the waiting list.

COVID-19 Vaccination Appointment Request