Vaccinations for individuals who are homebound- Pacific County
This form is for individuals who are homebound and who would like the COVID 19 vaccine. Health Department staff or another local vaccine provider will use this information to schedule appointments with you to come out to your home to provide the vaccine. Please fill out a separate registration form below for each individual who needs a home based vaccination. This is a secure form and any information you submit to us via this form, such as your contact information and address, is protected.
Once the survey is submitted, you will see a message informing you that the form has been accepted. Depending on the survey response, we will either contact the individual needing the vaccination or the one who submitted the survey. For any questions, please call 360-875-9407.
First name of person completing this form
Last name of person completing this form
Phone number of the person completing this form
Email address of the person completing this form
What is your relationship to the individual who needs a homebased vaccination?
Community based representitive
Other, please explain below
Patient First Name
Patient last name
Phone number of the patient
Email address of the patient
What is the best way to contact the individual who needs to be vaccinated?
Please contact the person submitting this request
Please select the option that best describes your situation
I can leave the home to get vaccinated, but need transportation
I am unable to leave the home
Is there anything else you would like us to know?
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