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COVID-19 Vaccine Registration

  1. PLEASE COMPLETE THIS FORM INDIVIDUALLY AND DO NOT COMBINE YOUR REGISTRATION WITH OTHER MEMBERS OF YOUR HOUSEHOLD

  2. Do you have a Primary Care Provider? *

  3. Before submitting this form, please verify all of your information is correct.

  4. *Disclaimer

    The information provided in the form below will be used to match eligible individuals with health care providers that have available vaccine. The information on this form may be shared with healthcare entities beyond Walworth County Public Health for purposes of vaccination services only.
    *If you do not select to receive an email copy of this form you will not receive a confirmation of submission. Please do not submit this form multiple times.

  5. Leave This Blank:

  6. This field is not part of the form submission.