LVD Health Center COVID-19 Vaccine Registration Form
Thank you for your interest in receiving the COVID-19 vaccine from Lac Vieux Desert Health Center!
This 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. We will follow tribal and national guidelines to schedule patients. After we receive your completed pre-registration, you will be notified via email when vaccine is ready.
If you are pregnant, please talk to your doctor prior to registering to determine if you should receive your vaccine.
Please fill all required fields to submit you pre-registration.
Are you an enrolled Native American tribal member?
Prefer not to answer
If answer to above question is yes, please indicate tribe.
Do you currently receive your primary care at the LVD Health Center?
Are you a healthcare provider, healthcare personnel, or do you work in a healthcare facility?
Do you work in one of the following fields: fire/rescue, law enforcement, childcare or education?
Do you have a compromised immune system or any of the following medical conditions: chronic heart, lung, or kidney disease, diabetes, obesity, cancer, sickle cell disease, and/or a transplant patient?
Email - You will be contacted by email for confirmation and scheduling.
Please enter a valid phone number.
Street Address Line 2
State / Province
Postal / Zip Code
I hereby declare that all the given information are accurate.
Yes, my information is accurate.
Should be Empty: