COVID-19 Vaccine Pre-Registration
Thank you for your interest in receiving the COVID-19 vaccine. This pre-registration is only for people who have not received a dose of the COVID-19 vaccine. If you have received a dose of the COVID-19 vaccine already, please exit this registration and connect with the facility that vaccinated you to schedule your second dose or call our office to see how we can help at 715-536-0307. By administering the COVID-19 vaccine, we will improve the health and safety of our communities as we continue to move through this pandemic. LCHD will follow state eligibility guidelines to schedule clients. Pre-registering will allow us to notify you of vaccine appointment availability after we have received the vaccine.
Client Name
*
First Name
Last Name
Eligibility Status
*
Ages 12 and over
Which vaccine are you interested in?
*
Pfizer
Johnson & Johnson/Janssen
Either
When are you available to receive the vaccine? (check all that apply)
*
Mornings (Before 10am)
Afternoons (10am - 3pm)
Night (After 3pm)
What days of the week work best for you? (check all that apply)
*
Monday
Tuesday
Wednesday
Thursday
Friday
Where do you work?
Please put where you work, so we can verify eligibility. If you are 65+, enrolled in the Medicaid Long-Term Care Program, or have a medical condition you may skip this question.
Gender
*
Female
Male
Ethnicity
*
Hispanic
Non-Hispanic
Race
*
American Indian
Asian
Black/ African American
White
Other
Accommodations Needed for Clinic
Birthdate
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Address
*
City
*
Zip Code
*
Email
example@example.com
Submit
Should be Empty:
Now create your own JotForm - It's free!
Create your own JotForm