COVID Vaccine Phase 1B
Please fill out the following form if you are interested in receiving a COVID vaccine.
Missouri has moved into Phase 1B, Tier 1 as of Thursday, 1/14/2021 and will move into Phase 1B, Tier 2 on Monday, 1/18/2021. We must verify patient eligibility in each Tier in order to give the vaccinations. Once this form is filled out, we will review it and reach out to you by email to schedule an appointment based on vaccine availability. Those that qualify in Tier 1 are: Public Health Administrators and Staff, Law Enforcement, Fire Services, Corrections, Emergency Management, Public Works and Emergency Services. Those that qualify in Tier 2 are: Anyone 65 years old and older and any adults with: Cancer, Chronic Kidney Disease, COPD, Heart Conditions, Weakened Immune System due to Organ Transplant, Severe Obesity (BMI > 40), Pregnancy, Sickle Cell Disease, Type 2 Diabetes, Individuals with Intellectual and/or Developmental Disabilities.
Please enter a valid phone number.
Date of Birth
Street Address Line 2
State / Province
Postal / Zip Code
Are you an eligible worker based on Tier 1?
If yes, please select your role.
If you selected a role above, please list your employer
Are you 65 years old or older?
Are you less than 65 years old but have a qualifying condition?
If you answered yes, please select the condition(s)
Chronic Kidney Disease
Weakened Immune System due to Organ Transplant
Severe Obesity (BMI > 40)
Sickle Cell Disease
Type 2 Diabetes
Intellectual and/or Developmental Disorders
I attest that all of the information provided above is true to the best of my knowledge.
Name and Date (MM/DD/YYYY)
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