COVID-19 Vaccination Signup

COVID-19 Vaccination Signup
This form will put you on a list that allows Mahaska County Public Health to be ready for vaccine distribution. Vaccines are minimal at this time, and we will be notifying individuals based on the approved groups set by the State of Iowa.
Salutation

None Mr. Ms. Mrs. Dr. Prof.
First Name *
Middle Name
Last Name *
Are you 65 or older *

Yes No No, but I have health issues
Date of Birth *

Month Day Year
Date
Phone Number *
Please enter a valid phone number.
Street address *
City *
State *
ZIP Code *
Please check any of these medical conditions you have:

Diabetes mellitis Chronic lung disease (asthma/emphysema/COPD) Chronic kidney disease Autoimmune disease Disability (neurologic, neurodevelopmental, intellectual, physical) Heart disease High blood pressure Immunosuppressive condition Other
Please list any allergies
List any other recent vaccines in the last 2 weeks
Email

Confirmation Email Confirm E-mail Address
Do you require assistance upon arrival?

Yes
Should be Empty: