COVID-19 Vaccine Registration Form

COVID-19 vaccine is authorized for people age 6 months and older.

Please select the option that applies to you.*

Yes, I am or are requesting for someone 6 months of age or older.No, I am not 6 months of age or older.

You aren’t currently eligible to get COVID-19 vaccine.

Need help finding COVID-19 vaccine?

Anyone 6 months of age or older can be signed up for Tacoma-Pierce County Health Department’s Vaccine Help List.

We’ll contact you by phone or email and connect you with vaccine opportunities.

We can help find:

First, second, third or booster doses.
Moderna, Pfizer or Novavax vaccine.
Appointments at healthcare facilities, pharmacies and vaccine events.
Walk-up events.
Help with transportation to appointments and events.
Mobility assistance and language support at appointments and events.

Our partner healthcare systems may also access the list and contact you with vaccine opportunities.

Questions?

Call us at (253) 649-1412, 8 a.m. to 4:30 p.m., 5 days a week.

You can unsubscribe from the list online or by phone at (253) 649-1412, 8 a.m. to 4:30 p.m., 5 days a week.

You can always check our website, tpchd.org/vaxtothefuture, for vaccine events and the state’s vaccine locator tool, vaccinelocator.doh.wa.gov, for nearby healthcare providers and pharmacies with vaccine.

First Name*

Last Name*

Date of Birth*

Date

Zip Code*

Zip Code

Enter your email address below to receive an appointment opportunity.

Email

example@example.com

Phone Number*

Please enter a valid phone number.

Preferred contact method?

EmailPhoneBoth

What dose are you looking for?

1st dose2nd dose3rd doseBooster dose

Date of your first dose?

Date

Your second and third dose MUST be the same vaccine as your first dose.

Vaccine Preference

Any AvailableModerna (age 6 months or older)Pfizer (age 6 months or older)Novavax (age 12 or older)

Do you need any assistance to get your vaccine?*

What language do you need assistance with?

What mobility assistance do you need?

COVID-19 Vaccine Help List