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English (US)
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!
Please complete this pre-registration form if you would like to start/complete your vaccine series OR if you are interested in receiving a booster dose.
After we receive your completed pre-registration, you will be contacted by a member of our staff to schedule an appointment.
**IF YOU ARE SIGNING UP FOR THE NEW OMICRON BOOSTER, YOU WILL BE PLACED ON A WAIT LIST AND CONTACTED WHEN THE VACCINE BECOMES AVAILABLE.
Please fill all required fields to submit your pre-registration.
Are you an enrolled Native American Tribal member?
*
No
Yes
Prefer not to answer
If answer to above question is yes, please indicate Tribal affiliation:
Do you currently receive your primary care at the LVD Health Center?
*
Yes
No
Have you ever received a COVID19 vaccine?
*
Yes
No
Please provide the manufacturer and date for each dose you have received:
*
Which manufacturer would you prefer?
*
Moderna
Novavax
Which manufacturer would you prefer for the booster?
*
Moderna
NEW Omicron Booster (NOT YET AVAILABLE)
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Registrant Demographics
Name
*
First Name
Last Name
Birth Date
*
-
Month
-
Day
Year
Date
Gender
*
Female
Male
Transgender
Non-binary
Prefer not to answer
Age
*
Email
*
Confirmation Email
example@website.com
Phone Number - we will contact you for more information
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
I hereby declare that all the given information are accurate.
*
Yes, my information is accurate.
Register
Should be Empty: