COVID-19 Vaccine Clinic Notification
If you would like to receive communication about COVID-19 Vaccination Clinics at Stoughton Health, please enter your contact information below. Please note that we will be reaching out regarding clinics via e-mail. **We are currently sending out vaccine invitations as quickly as possible based on our doses available and the Wisconsin Guidelines. At this time, our requests far exceed our supply of vaccine. Please be patient as we work diligently to promptly vaccinate all persons wanting a vaccine. You do not need to complete this form more than once unless your information has changed.**
Name
*
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
*
Confirmation Email
example@example.com
Age
*
0-16 years old (no vaccines currently approved)
17 years old
18-64 years old
65-69 years old
70-74 years old
75 years or older
Zip Code
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I am in one of the following groups:
Tier 1A Healthcare Provider
Tier 1B Police/Fire
Tier 1B K-12 Education
Tier 1B Preschool/Childcare
Tier 1B College Level Educator
Tier 1B Medicaid Long Term Care Program Enrollee (IRIS, Family Care, Katie Beckett and Children's Long Term Care Waiver)
Tier 1B Public Facing Essential Worker (911 Operator, Utility and Communications Infrastructure, Public Transport, Food Supply Chain)
Tier 1B Non-frontline essential healthcare personnel
Tier 1B Mink Husbandry
Tier 1B Congregate Living
Comorbidities or other high risk person
None of the above
Other information you would like to provide (please note that due to the number of requests receive, we may not be able to review all individualized information provided here):
Submit
Should be Empty: