HCH COVID-19 Vaccine Interest Form
Hale County Hospital is collecting information for all people who are interested in the COVID vaccine. We DO NOT know when we will receive vaccines. Please fill out all the following information for the person who would like to receive the vaccine and we will get back to you as soon as we have vaccines on hand.

*FILLING OUT THIS FORM DOES NOT GUARANTEE YOU HAVE AN APPOINTMENT OR THAT YOU WILL RECEIVE THE VACCINE*

This is only an interest form for our waitlist and we will call you to let you know when we have more information.
Sign in to Google to save your progress. Learn more
What is your full name? *
How old are you? *
What is the best phone number to reach you? *
Is there another phone number you would like to add?
What is your occupation?
Where do you live? (Please list town, zip) *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Halecohosp.com. Report Abuse