COVID-19 Vaccination Notification

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If you are interested in getting the COVID-19 vaccination, please complete the following form.

We currently have walk-in clinics and have listed the dates and times of those clinics below. If you or those that might be coming with you are not fully vaccinated for COVID-19, please make sure to wear a face covering when coming to our building/office.

If you should have any additional questions please feel free to call our office at (719) 336-8721. Please complete only one response for each person.

First and Last Name *

Date of Birth *

YYYY

Current Age *

Contact Phone Number (with area code) *

Which COVID -19 Vaccine are you interested in?

For a child ages 5 to 11

Pfizer - 2 doses, 21 days apart for 12 years of age and older

Moderna - 2 doses, 28 days apart for 18 years of age and older

J & J - 1 dose, for 18 years of age and older

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