Chicago Behavioral Hospital Vaccine Contact Form

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Please complete this form if you are interested in receiving information about vaccines at Chicago Behavioral Hospital.
*This form is for receiving information only. It does not guarantee vaccine availability or a vaccine appointment.*

First Name *

Last Name *

Date of Birth *

YYYY

Phone number *

Email *

Are you a resident of Cook County? *

Yes

Are you eligible to receive a vaccine based on current eligibility criteria? *

For more information on eligibility: https://coronavirus.illinois.gov/s/vaccination-plan-overview

Yes

Additional information

Any questions or comments can be emailed to WeCare@chicagobehavioralhospital.com

Submit

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