Roosevelt COVID-19 Vaccine Clinic

Roosevelt 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 the ROOSEVELT office. NOTE, this is a two series vaccine you will need to scheduled your second dose of the vaccine 28 days after you receive your first dose. Please make the appropriate arrangements to receive your second dose as scheduled at the end of this form.
Name *

First Name Last Name
Please select your county of residence area?
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, Healthcare worker, Educator? *
TriCounty Health is currently only scheduling vaccines for individuals 65 years old and older.
The TriCounty Health Department is currently only vaccinating individuals over the age of 65, Healthcare workers, and teachers. Please continue to review the health department's webpage for updates.
Personal Information

Please include your personal information.
Birthdate *

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

Please provide insurance information. Click on the link below to learn why we collect insurance information.
Why we collect insurance information.
Insurance Provider
Insurance Group Number
Insurance Policy Number
Social Security Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Please select your appointment time for your first shot *
Please select an appointment for your SECOND shot (At least 28 days from your first Shot). *
Should be Empty:

Roosevelt COVID-19 Vaccination Clinic

Personal Information

Insurance Information