Livingston County Health Center Survey

Are you interested in receiving the COVID-19 vaccine?

SIGNING UP DOES NOT SCHEDULE YOUR APPOINTMENT, YOU MUST CALL TO GET AN APPOINTMENT WHEN CLINICS ARE ANNOUNCED

Based on availability, and guidance from the Missouri Department of Health and Senior Services (MO DHSS) and the Center for Disease Control (CDC), the Livingston County Health Center will be providing the COVID-19 vaccine based on a pre-determined phase system. Individuals will be identified to receive the vaccine based on risk status and occupation. Vaccines will be limited based upon the quantity provided by the State of Missouri.

Once the vaccine is made available for your phase, the Livingston County Health Center will use your information from the survey below to contact you with further instructions on how to schedule an appointment to receive your vaccination.

You are required to fill out the survey completely to be added to the list.
COVID-19 vaccinations will not be provided to those under the age 18.
Consult your physician before taking the vaccine.

By completing this survey, you agree to receive text, phone call or email regarding COVID-19 vaccine availability and clinic opportunities based on your assigned phase. Message and data rates may apply.

Question Title

* 1. What is your name?

First Name

Last Name

Question Title

* 2. What is your current age?

Question Title

* 3. What is your zip code? (Livingston County, Missouri Residents ONLY.)

64601 Chillicothe & Surrounding

64635 Chula

64638 Dawn

64656 Ludlow

64664 Mooresville

64686 Utica

64688 Wheeling

Question Title

* 4. What is your phone number?

Question Title

* 5. What is your email? (Optional, used to alert you when vaccine is available.)

Question Title

* 6. Do you have any pre-existing medical conditions? Please select all that apply.

Diabetes

Hypertension

Heart Condition (i.e. heart failure, coronary artery disease, cardiomyopathy, etc.)

Morbid Obesity (BMI over 40)

Chronic Kidney Disease

Chronic Liver Disease

Chronic Lung Disease (asthma/emphysema/ COPD)

Autoimmune Condition

Immunocompromised Condition

Pregnancy

Sickle Cell Disease

Condition Not Listed

No Pre-Existing Conditions

Livingston County Health Center Survey

Are you interested in receiving the COVID-19 vaccine?

Question Title

* 1. What is your name?

Question Title

* 2. What is your current age?

Question Title

* 3. What is your zip code? (Livingston County, Missouri Residents ONLY.)

Question Title

* 4. What is your phone number?

Question Title

* 5. What is your email? (Optional, used to alert you when vaccine is available.)

Question Title

* 6. Do you have any pre-existing medical conditions? Please select all that apply.

Question Title

* 7. What is the name of your primary care provider? (Doctor, Nurse Practitioner, Physicians Assistant) Answer "NA" or "None" if you don't have one.