SAN JUAN COUNTY PUBLIC HEALTH COVID19 VACCINATION REGISTRATION (vers. 3.0)

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

AS OF APRIL 2, 2021 COVID-19 VACCINATIONS ARE OPEN TO THE GENERAL PUBLIC (18 years and older)

**********SJCPH is a FRONTIER CLINIC and has limited staffing.**********

Definitive medical care is over an hour to the North or South over mountain passes. EMS transport may be delayed due to hazardous conditions.

COVID-19 vaccinations are generally scheduled for Wednesdays and Thursdays 10am - 1pm

Sign up and a staff member will contact you to arrange an appointment.

SAN JUAN COUNTY PUBLIC HEALTH (SJCPH) 1315 Snowden Street Silverton, CO 81433

PHONE: (970) 919-0130 or 970-387-0242

All information entered is strictly confidential and will not be used outside of SJCPH, except for insurance billing purposes and when required by law.

Expect a minimum of 30 minutes for your appointment as you will be required to be monitored for 15 minutes post-vaccination.

1) Please fill out a separate registration for each person who will be receiving a COVID-19 vaccination.

2) Please wait in your car at the front entrance on Snowden street so our staff can see you. Wear a mask and clothing such as a t-shirt under your jacket. You will be vaccinated outside in or near your vehicle. If you are a walk up, please wear a mask and wait for your appointment and staff will invite you into the building.

The vaccine you will receive depends on the vaccine inventory on hand the day of your appointment.

Email *

NAME (Last, First, Middle Initial) *

Date of Birth *

YYYY

Age *

Phone Number *

Physical Address (City, State, County, Zip Code) (If you do not have an address write no address) *

Have you had a severe allergic reaction to other vaccines or injectable medication? As an example, an allergic reaction is considered severe when a person needs to be treated with epinephrine or EpiPen© or if they must go to the hospital. *

Yes

Required

I am available to fill in for open appointment slots or extra doses available

Yes

Clear selection

Any other relevant information that you would like us to know?

SJCPH staff will contact you on the next available appointment

You will be asked to schedule 2 appointment dates for 2 separate doses

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of San Juan County. Report Abuse

Forms