DCH Health System COVID-19 Vaccine Registration

Vaccination Scheduling
Please select an appointment time:*
Patient Information
Select your qualifying category*
Details will be verified at the time of vaccination.
Qualifying Category (Other)
Please provide your qualifying category.
Name*

First NameMiddle NameLast NameSuffix
Employer*
Please provide the name of your employer. If you are not employed, indicate "NA".
Sex*

MaleFemale
Date of Birth*

MonthDayYear
You do not meet the criteria outlined for our current Qualifying Categories, we can not schedule you for an appointment at this time.
Please note that a parent or guardian must accompany, and sign a consent form for, any individual between the ages of 12 and 17 who wishes to receive the vaccine.
Social Security Number
Address*

Street Address

Street Address Line 2

CityState

Zip Code
First Name
Last Name
Phone Number*
Please enter a phone number we can reach you at if necessary.
Email Address

Confirmation Emailexample@example.com Please enter a valid email and confirm this email in the second text box. This email will only be used for correspondence regarding this appointment.
Insurance Information
Insurance Provider*
Please select your primary insurance provider
Other Insurance Provider
Insurance Policy Number
Please provide your insurance policy number
Insurance Group Number
Please provide your insurance group number
Insurance Responsible Party
Please provide the person listed as Responsible Party on your insurance policy. May also be listed as Subscriber.
Please bring your driver’s license or proof of ID when coming to the vaccination site.
Should be Empty:

Request a COVID-19 Vaccination Appointment

Vaccination Scheduling

Patient Information

Insurance Information