Vernal COVID-19 Vaccination Clinic

Vernal COVID-19 Vaccination Clinic

TriCounty Health Department receives a limited number of COVID-19 vaccine weekly. Please complete this form and select an appointment time from the available dates and times in our VERNAL location. NOTE, this is a two series Vaccine you need to schedule your second dose of the vaccine 28 days after you receive your first dose. Please make the appropriate arrangements and schedule on the form below.
Vernal vaccinations will be done at the Uintah Conference Center starting Feb. 23, 2021

313 E. 200 S. Vernal
Name *

First Name Last Name
Please select your county of residence *
Vaccines provided at the TriCounty Health Department are intended only for individuals who live in the TriCounty area, Daggett, Duchesne, and Uintah Counties. If you live in another county please contact your local health department for information on how you can receive your COVID-19 vaccine.

Thank You
Are you 65 years of age or older, a healthcare worker, or educator? *
TriCounty Health Department is currently providing vaccines for individuals over the age of 65. Please continue to check the TriCounty Health Department website for more information for other age groups to receive the vaccine.

Thank You
Personal Information
Birthdate *

Month Day Year
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Insurance Information.

Please include insurance information. The COVID-19 vaccine is free but Doctors and nurses may be reimbursed by insurance companies for administering the shot. Please click the link below to review why we collect this information.
Why we collect insurance information
Insurance Provider
Insurance Group Number
Insurance Policy Number
Social Security Number
Please select your appointment time for your first shot *
Please make your appointment for your second shot (AT LEAST 28 days from your first Shot). *
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Vernal COVID-19 Vaccination Clinic

Vernal vaccinations will be done at the Uintah Conference Center starting Feb. 23, 2021

Personal Information

Insurance Information.