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.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you an eligible worker based on Tier 1?
Please Select
Yes
No
If yes, please select your role.
Please Select
Public Health
Law Enforcement
Fire Services
Corrections
Emergency Management
Public Works
Emergency Services
If you selected a role above, please list your employer
Are you 65 years old or older?
Please Select
Yes
No
Are you less than 65 years old but have a qualifying condition?
Please Select
Yes
No
If you answered yes, please select the condition(s)
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
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)
Submit
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