Talbot County Health Department Vaccine Interest Form for Residents of Talbot County Aged 16 and Older

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

This form collects contact information for people who are interested in receiving the COVID 19 vaccine.

This form is *NOT* a registration for a COVID vaccine appointment. When appointments are available, you will be emailed with specific instructions on how to schedule your vaccination appointment.

Please submit a separate form for each interested person.

If you do NOT have access to a valid email address, please contact the vaccination call center. The call center is available Monday through Friday 9am-4pm by calling 410-819-5641.

After completing this form, you will receive an email containing your responses, as long as the email address is valid. You will also have the opportunity to sign up for weekly email updates from the Talbot County Health Department regarding vaccinations.

*If you have previously pre-registered on the forms meant for 65-74 year olds and individuals aged 75 and older, we have your information and will continue to provide updates and vaccine appointment emails. You do not need to pre-register again on this form*

Check talbotcovid19.org and https://health.maryland.gov/talbotcounty/Pages/Covid-Info.aspx for up to date local information.

Thank you for your interest in getting vaccinated!

Email *

Last Name *

First Name *

Enter your date of birth in format mm/dd/yyyy. You can also use the calendar icon to pick your birthdate. *

YYYY

Primary phone number (format 999-555-1234) *

Alternate phone number (format 999-555-1234)

What is your preferred contact method? *

Primary phone number

Alternate phone number

Other:

Please enter your town/city of residence *

Please enter your 5-digit zip code of residence *

Underlying Medical Conditions

Cancer ~ Chronic kidney disease ~ COPD (chronic obstructive pulmonary disease) ~ Asthma (moderate-to-severe) ~ Interstitial Lung Disease ~ Cystic fibrosis ~ Pulmonary Hypertension ~ Pulmonary fibrosis (having damaged or scarred lung tissues) ~ Down Syndrome ~ Heart conditions, such as heart failure, coronary artery disease, cardiomyopathies, or hypertension (high blood pressure) ~ HIV infection ~ Immunocompromised state (weakened immune system) ~ Overweight or Obesity ~ Pregnancy ~ Sickle cell disease or Thalassemia ~ Smoking (current or former) ~ Diabetes (Type 1 OR 2) ~ Solid organ or blood stem cell transplant ~ Stroke or Cerebrovascular disease ~ Substance Use disorders ~ Neurologic conditions, such as dementia ~ Liver disease
See current list of high-risk medical conditions here: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html

Do you have any of the above medical conditions? *

Yes

Are you able to drive to a vaccine appointment? *

Yes

Do you need language services or accommodations for a disability? *

Yes

Do you have access to the internet to register for a vaccination appointment when they become available?

Yes

Clear selection

Thank you for your interest in getting vaccinated!

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of State of Maryland. Report Abuse

Forms