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All individuals who are currently eligible for COVID-19 vaccination should complete this form. Those who complete the form who are not yet eligible to receive a vaccine will NOT be contacted.
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.
This field is not part of the form submission.
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