COVID & Flu Vaccine Appointment Form

COVID & Flu Vaccine Appointment Form

Please Note: At this time, we only have Pfizer COVID vaccine for 12yrs and up. We are waiting for our shipment of Moderna 12yrs and up & Pfizer 6m-11yrs. The Moderna 6m-11yrs is still unavailable to order at this time.
Please select a time for your vaccination appointment*
Please note that all appointments are being held at the Gallatin City-County Health Department located at 215 W Mendenhall St.
Personal Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
What is your age?*
If under 1 year of age, please enter 0.
What is your gender?*
What is your race?
What is your ethnicity?
Email*
A confirmation of your appointment will be sent to the email address entered above.
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip Code

Vaccine
Select which Vaccine you need.*

Updated 23-24 COVID (12yrs & up) Vaccine OnlyFlu Vaccine OnlyFlu & COVID(12yrs & up)

Personal Information