COVID-19 Vaccine Registration Forms

Please read before submitting form below: 

All recipients will be expected to fill out a Vaccine Registration Form even if you utilized the "Self-Scheduling" feature. To speed up the process on your appointment day, fill out the form completely and SAVE. There is no need sign the form (you can sign when you get to the Vaccine Clinic.) Once the form is filled out and saved, email it to *Please note that depending on the type of internet browser you are using (Google Chrome, Firefox, Internet Explorer, etc.), the ability to download and save may look different. Always check the file before sending to make sure all the information you filled was saved. Someone will call to schedule your appointment. 

You can also print out this form and bring it with you on your appointment day.  

What to bring to Vaccine Clinic for Scheduled Appointment 

  • Photo ID
  • Any applicable medical insurance card(s)

Note: if you participate in a Medicare Advantage Plan, the COVID-19 administration claim must be submitted to your Original/Traditional Medicare plan (red/white/blue card). Fill out your Original/Traditional Medicare information on this form and/or bring your card to your appointment.


COVID-19 Registration Forms (Please fill out form. Do not sign - you will sign at your scheduled appointment)