Laurel County Health Department - COVID-19 Vaccine Request for Phase 1B - Seniors age 70 and over
This information remains confidential. Make sure to provide accurate information, as our staff will need to follow-up for additional details. LCHD will maintain a list of individuals to be vaccinated as soon as possible through Phase 1b, and additional phased. THIS IS NOT AN APPOINTMENT!!!
PLEASE NOTE: Long-term care residents are being vaccinated by way of a federal contract with CVS & Walgreens.
* Required
First & Last Name
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Your answer
Phone Number
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Your answer
Address
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Your answer
Birthdate MM/DD/YYYY (Reminder: this is for individuals 70 and older)
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MM
/
DD
/
YYYY
Email
Your answer
County of Residence
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Your answer
Please list any underlying health conditions that you have.
Your answer
Statement of Understanding
This is for Local Laurel County Residents and NOT the state of Kentucky. I agree and understand that the above information is correct. Each record will be reviewed by LCHD staff. I understand that this process will be used as a tool to evaluate the number of individuals that would like the vaccine when it is available to their respective tier. We will use the information above and will contact you. We will also post information about vaccination efforts on our website (
www.laurelcohealthdept.org
) and Facebook page.
Typing the secret word: tomato below means you have read and understand the previous statement. Again, this is NOT registration for an appointment.!!!!
Please type the Secret Word above in ALL CAPS.
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Your answer
Notes (this section to be completed by health department staff)
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