Thank you for contacting us regarding your out of state COVID-19 vaccination. Please complete this survey to submit your information, a photo of vaccine card, and a photo ID or license. Complete one survey per recipient of an out of state vaccination.

If you are unable to complete the online survey, please visit one of our office locations. If further assistance is needed call 800-386-5959 or e-mail covid19vaccination@nwhealth.org. 

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* 1. Legal name

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* 2. Date of birth

Date

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* 3. Phone number

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* 4. Mailing address

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* 5. Submit a photo of the front of your vaccination card.

PDF, DOC, DOCX, PNG, JPG, JPEG file types only.
Choose File

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* 6. Submit a photo of the front of your photo ID or license.

PDF, DOC, DOCX, PNG, JPG, JPEG file types only.
Choose File
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