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 75 years and older effective January 18, 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. If you are available on short notice to fill in gaps in our schedule, please indicate that below.
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
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 had a positive diagnosis of COVID-19 at any time. *

Yes No
I am interested in being called on short notice if a work-in appointment is available.

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
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COVID-19 Vaccination Appointment Request

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

COVID-19 Vaccination Appointment Request