COVID-19 Vaccine Registration

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If you would like to receive the COVID-19 vaccine, please complete this form. Vaccines are currently limited. Registration will allow Lakeshore Community Health Care plan for and distribute the vaccine as quickly as possible to those eligible, based on guidance from the Centers for Disease Control and Prevention (CDC) and Wisconsin's phased distribution plan.

If you believe you fall into an essential worker category, please bring your work ID, badge, paystub or a letter from your employer as proof of eligibility.

First and Last Name *

Date of Birth *

YYYY

Where do you live? *

Sheboygan County

Manitowoc County

Other:

Phone Number *

Email Address *

Are you currently a patient at Lakeshore Community Health Care? You do not need to be a patient to receive the vaccine. (Please check all that apply. ) *

Medical or Mental Health

Chiropractic

Dental

Other:

Required

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