Request for COVID-19 Vaccination

COVID-19 Vaccination for 65+ individuals and high-risk adults

The following information will allow Audrain County Health Department to place you on our contact list. We will contact you when we have available COVID-19 vaccine, direct you to other vaccination sites or share your contact information with other vaccinators.

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* 1. What is your contact information?

Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Primary Phone Number

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* 2. What is your email address?

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* 3. Are you an Audrain County resident?

Yes

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* 4. What is your cell phone number?

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* 5. May we text you regarding COVID-19 and other public health information?

Yes

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* 6. Do you have any of the following health conditions? Check all that apply.

Type 2 Diabetes

Sickle Cell Disease

Pregnancy

Severe Obesity

Immunocompromised state from solid organ transplant

Heart Conditions

Developmental Disabilities

COPD

Chronic Kidney Disease

Cancer

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* 7. What is your age?

16-24

25-34

35-44

45-54

55-64

65-74

75-84

85+

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* 8. Have you ever tested positive for COVID-19?

Yes

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* 9. Some vials come with an extra dose. Please check this box if you could be at Audrain County Health Department within 30 minutes to take advantage of this extra dose so it doesn't go to waste.

Yes, I can arrive at the health department within 30 minutes for a rush vaccination.