Mpox Vaccine Waitlist

At this time, the vaccine is only available for individuals who are at the highest risk for Mpox. Based on your eligibility, you will be placed on our prioritized waitlist and will receive a phone call to schedule an appointment when vaccines are available. Please note: submitting this form does not guarantee that you will be contacted for an appointment. If you do not meet eligibility requirements, you will be removed from this list and will not receive a follow-up call.

IMPORTANT: If you have been exposed to someone with confirmed or probable Mpox infection, please call us at _____. You do not need to complete this form.

If you are experiencing any symptoms of Mpox, please isolate and contact your primary care provider immediately.

Name

First NameLast Name

Date of birth

Date

Phone Number

Please enter a valid phone number.

County of Residence

Please list all of your individual risk factors for mpox (if none, type "None"):

A risk factor is anything that increases your chances of becoming infected with mpox. For more information on potential risk factors, visit: https://www.cdc.gov/poxvirus/monkeypox/vaccines.html