COVID-19 Vaccine Request Form
Thank you for your interest in receiving the COVID-19 Vaccine. BETHLEHEM FAMILY HEALTHCARE has been approved as a mass vaccination site. You do not need to be an established patient with BETHLEHEM FAMILY HEALTHCARE to schedule your vaccination.

Please complete this Request Form AND the Pre-Registration Form. Your personal information will be kept confidential per HIPAA policies. We will only schedule if BOTH FORMS ARE COMPLETED. We will call you back in the number provided to confirm your schedule.

Other than sharing your information through the Georgia Vaccine Registry and the Georgia Department of Public Health, your information will not be sold or shared. It will only be used for coordination of your COVID-19 vaccination.

Please bring photocopies of your health insurance card, (front and back, including Medicare if applicable) AND valid photo ID (photocopy), to expedite the process. The state GRITS vaccine registry may require your SSN on the date of appointment.

See FAQs section down below for more information.

Sign in to Google to save your progress. Learn more
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy