Chickahominy COVID-19 Vaccine Clinics
Please fill out a survey for each person that would like a COVID-19 vaccination. We are offering COVID-19 vaccines for individuals aged 5+. We are now offering boosters for individuals aged 5+.

Please indicate your preferences and enter your contact information below. A member of our team will reach out to you to schedule your appointment.

Sign in to Google to save your progress. Learn more
Email *
First Name *
Last Name *
Date of Birth *
Address, including county and zip code: *
Phone Number *
If you are contacting us on behalf of another person, please enter their name/names here:
If you have difficulty with mobility or transportation, we can send a mobile unit to your home. If you represent a business with multiple employees, we can schedule a clinic for your business. Would you like a mobile unit to visit you at home or at work? *
If you would like the mobile vaccine team to visit you, please enter the address you would like for them to visit here (if the address is different from the address you previously entered):
If you would like to make an appointment to attend a public clinic, please indicate your availability here: *
Clinics are updated weekly. If you do not see a date that works for you, visit to find vaccination sites near you! For appointment clinics below, add a note in the comment section if you have a preferred time and we will do our best to accommodate you.
If you require special accommodations/considerations for your clinic appointment, please describe:
Vaccine Preference *
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy