Talbot County Health Department COVID Vaccination - Pre-Registration for Talbot Residents Aged 75 and Older

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Talbot County is in Phase 1B as of the week of 1/18/21. Phase 1B includes individuals age 75 and older.
Talbot County residents aged 75 and older who are interested in receiving a COVID vaccine are invited to complete this form.

THIS FORM IS *NOT* A REGISTRATION FOR A COVID VACCINE.
THIS FORM COLLECTS THE CONTACT INFORMATION OF PEOPLE INTERESTED IN GETTING VACCINATED. Please complete this form so the Health Department can contact you with instructions on how to register for a vaccine clinic when vaccine is available.
You will receive an email response notifying you that your information has been received.

WHEN VACCINE IS AVAILABLE, YOU WILL BE EMAILED BY THE HEALTH DEPARTMENT INSTRUCTIONS ON HOW TO SCHEDULE AN APPOINTMENT FOR A VACCINE.

Please complete a separate form for each person who is interested in receiving the vaccine and is 75+ years old.
If you are not 75+ years old, please complete the form for the group you belong to.

You may pre-register on behalf of someone who is unable to complete this form themselves due to disability, lack of internet, lack of email address , etc.

A vaccination call center is available to answer questions about the vaccination process in Talbot County Monday through Friday 9am-4pm by calling 410-819-5641.

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

PLEASE NOTE THAT VACCINE QUANTITIES ARE EXTREMELY LIMITED EACH WEEK AND WE APPRECIATE YOUR PATIENCE THROUGHOUT THIS PROCESS.
Thank you for your interest in getting vaccinated!

Email *

First Name *

Last Name *

Age *

Do you have any medical conditions that put you at higher risk for severe illness of COVID-19? See the list of conditions at: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html

Yes

Other:

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Street Address

City/Town

Zip Code

Telephone

Do you drive or can someone else drive you to get a COVID-19 vaccination?

Yes

Other:

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Do you need accommodations for a disability or language services?

Can you register for vaccination online or could someone else help you register for vaccination online?

Yes

Other:

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Please add any additional information you feel we should know. Thank you for your interest in getting vaccinated!

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

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