COVID-19 Vaccine Waitlist
A new submission needs to be completed for each individual family member. Please be sure to complete the entire form prior to clicking the submit button.

PLEASE NOTE: ALL data submitted is stored on Google hosted servers and not protected by HIPAA. Therefore, the information submitted would not be covered by HIPAA laws. By submitting this form, you are agreeing to the above and to sharing the information provided to Boston Mountain Rural Health Center, Inc. and understand that while unlikely, this information could be viewed by others who might gain access to Google's servers where the information is stored. You also agree that Boston Mountain Rural Health Center, Inc. would not be held liable in the event this were to occur.
In the past 90 days have you tested positive for COVID-19? (If yes, please wait 90 days to complete this waitlist request form.)
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