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Columbia County Public Health
COVID-19 Vaccination Interest Form
This form is to signup to receive weekly COVID-19 vaccination updates. If you need help scheduling an appointment, call us at 503-397-7247.
First Name
Last Name
Phone Number
E-mail Address
example@example.com
Preferred method of contact
Phone
Email
Are you homebound?
Yes
No
Do you need help with transportation? If so, please explain need.
Do you have any other information you would like to share?
By checking this box, you agree to receive communications (email, text, phone) updates regarding COVID-19 vaccines from Columbia County.
*
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