Buffalo County COVID-19 Vaccine Interest Form

Buffalo County COVID-19 Vaccine Clinics
Name *

First Name Middle Name Last Name
Date of Birth

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Email
example@example.com
What is your race (please select only one) *

Black or African American Asian or Pacific Islander Native American or Alaskan Native White Other Prefer not to answer
What is your ethnicity? *

Hispanic Non-Hispanic Prefer not to answer
What is your preferred language? *
Ex. English, Spanish, Hmong
We have no control over what brand of vaccine we are going to receive each week. We strongly encourage that you take whatever appointments are available. If you can only receive a certain brand of vaccine, we cannot guarantee that we will be able to provide it to you. We urge you to contact your primary care provider or other vaccination sites, as they may be able to accommodate your request.
Are there any COVID-19 vaccine brands that you are unable to receive due to medical reasons? *If you are younger than 18, you may only receive the Pfizer vaccine* *

Moderna Pfizer Johnson & Johnson None
What is your preferred form of communication? This is how you will be contacted to schedule your appointment. If you select text message or email, you will receive a link to sign up. Phone calls will be from a Buffalo County Public Health employee. *

Text Message Email Phone Call
Hello! If you are looking for a first, second, or booster dose of either Pfizer or Johnson and Johnson, please visit one of our upcoming clinics. All clinics are walk-in, so no appointment is needed. The Buffalo County Health Department does not offer the Moderna vaccine.

Upcoming clinics are as follows:

Thursday, November 18 – Buffalo County Courthouse, 8-12 and 1-4 pm

Please reach out to the Buffalo County Health Department with any questions 608-685-4412.
I have read and understand the texting informed consents policy.

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Buffalo County COVID-19 Vaccine Clinics