Jefferson County, WV Health Department Services

Covid19 Vaccination Form Test

  • REQUESTOR CONTACT INFORMATION

    Please enter YOUR name and contact information. We'll gather information about the person to be vaccinated in the next step. Provide complete info so we can communicate with you when vaccine is available.
  • PERSON TO BE VACCINATED - INFORMATION

    Note that this a request to add this contact to our Vaccination Wait List. This is not a reservation for a particular date and time.
  • If available.
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    If available.
    MM slash DD slash YYYY
  • Comments or questions only! Please DO NOT share personal medical history on this form.
  • I understand and agree that any information submitted will be forwarded to our office by email and not via a secure messaging system. This form should not be used to transmit private health information, and we disclaim all warranties with respect to the privacy and confidentiality of any information submitted through this form.
  • This field is for validation purposes and should be left unchanged.