Appointment Request Form

Geary County Health Department

Covid 19 VACCINE FOR 16-18 year olds
Appointment Request

This appointment request form is for those 16-18 wanting the COVID19 vaccine (Pfizer). This does not guarantee you an appointment. This form is being used to see interest and book appointments by # of interested and vaccine inventory.
Student's Name*

First NameLast Name
Parent name*

First NameLast Name
Phone*

Area CodePhone Number
E-mail
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Should be Empty:

Geary County Health Department