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Thank you for reaching out to Community Health Care, Inc (CHC) regarding COVID-19 vaccination.

Please complete this form once per person you inquiring about. Please do not attempt to combine information for multiple individuals. Please do not complete this form more than once for each person requesting the vaccine. Repeated submissions for the same person will only cause delays. Si necesita esta forma en espanol por favor cambie el idioma en la esquina arriba a la derecha.

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1
Have you ever received a COVID vaccine 1st dose any place other than Community Health Care?* This field is required.
Yes
No
2
Do you live and/or work in any of the following:* This field is required.
Illinois - Rock Island County
Iowa Scott County
Iowa Clinton County
Iowa Muscatine County
None of the above
Should be Empty:

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