Lafayette County Health Department COVID-19 Vaccine Sign-up
This does not guarantee you an appointment or confirm your request. Further communication will come as details are available to the Lafayette County Health Department
Email address *
First name *
Last name *
Date of Birth *
MM
/
DD
/
YYYY
Phone Number *
Lafayette County County of Residence *
Occupation *
Name of Employer *
Do you have any underlying health conditions? *
Are you currently on any other vaccine waitlists? *
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy