COVID-19 Vaccine Interest Form for 65+

COVID-19 Vaccine Interest Form

65 years and older
Vernon County Health Department staff are currently working on identifying those that would like to receive the COVID-19 vaccine. We are currently working with health care workers, long term care staff/residents and those who are 65 years and older. More information to come on where and when you will be able to receive the vaccine. This is just the first step in identifying those that qualify. Please be patient, we will contact you when a vaccine is available. We still are working through the first waitlist. Please pay close attention to your email as this will be the perferred way of scheduling an appointment. Otherwise you will receive a phone call from a scheduler when a vaccine is available.
Name *

First Name Last Name
Email
example@example.com
Date of Birth *

Month Day Year
Date
Age: *
Phone Number (daytime) *
Please enter a valid phone number.
Phone Number (evening)
Please enter a valid phone number.
City of Residence *
Have you had COVID-19 within the last 90 days? *

Yes No
Are you 65 years or older? *

Yes No
Do you have chronic health conditions? *

Yes No
List any food, medication or vaccine allergies:
Please verify that you are human *
Should be Empty: