If you would like to be scheduled for vaccination please complete this form. St. Croix Regional Medical Center will contact you by email with more information when doses are available and you are eligible.
Which priority group are you a part of? (If you are both 65 years or older and have an underlying medical condition, please select 65 years or older)
65 Years or Older
Individual with Underlying Medical Conditions
General Public Vaccination after Priority Groups are Completed
Which type of essential worker are you?
Public health and safety
Food and Agriculture
Information and technology
Other critical infrastructure services
Each person needs their own form. If you are completing this form on behalf of a family member, please fill it out as if you are them.
Which age group do you fall in?
Age 75 and older
Under 18 is not eligible for a COVID-19 vaccine at this time
Primary Email Address (please be accurate, this is how you will be contacted. If none, write "none")
Primary Phone Number
Date of Birth
Have you had a history of, or are you currently (check all that apply)?
Severe allergic reaction (ex. anaphylaxis)
Immunocompromised (Do you take medications that weaken your immune system such as chemotherapy, steroids, injections for arthritis or psoriasis or other long term therapies)
Pregnant or breastfreeding
Should be Empty: