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 the first 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. 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 16 and over
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:
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