Complete this form for each person in your home who is age 18+. After you complete this form, you will be on a COVID-19 vaccination request list with public health. Our staff will then contact you to make sure you can receive the vaccine and schedule appointments as our supply permits. We kindly ask you to wait us to contact you rather than calling our office. This will help keep our precious phone lines open to make appointments. If you receive vaccination elsewhere, please share this information with our scheduling staff when they contact you so we can remove you from this list.
If you know someone who needs help filling out this form because they do not have a smart phone or internet access, assist them with completing this form or have them call
Please continue to follow face covering, hand washing, and social distancing recommendations. Stay safe and be well!
Special Notice: Completing a vaccination request form does not guarantee immediate appointment scheduling or vaccination. Some individuals may not be able to receive vaccination due to their specific health needs. The Minnesota Department of Health currently selects the vaccine brand we receive. We are unable to fulfill requests by specific brand.
System Maintenance Notice: Periodically, we may need to close this registration site to conduct upgrades or manage the list. If this occurs, try registering at another time. Thanks!