1B/C - Individual COVID Vaccine Survey
If you are 65 years or older and/or have underlying health condition (must be 18 or older to receive a Moderna vaccine) living in the Rappahannock Rapidan Health District and have a FIRM commitment to be vaccinated against COVID-19, please complete this survey to be placed on our vaccine list. The Rappahannock Rapidan Health District includes Culpeper, Fauquier, Madison, Orange and Rappahannock counties.
* This form is only to notify the Health Department of your specific demographics . We will be in touch by telephone with more information as it becomes available or to schedule an appointment, which could be several weeks from now.
* DO NOT fill out more than one survey. We only need one survey from you. Duplicate survey submissions slows our ability to serve you and others in the community
***Filling out this form does NOT guarantee availability of vaccine to you immediately. It simply makes us aware of your need to be vaccinated and specifics for us to contact you. We will be in touch by email or phone once we have sufficient quantity of vaccine to vaccinate you***
*** If your place of residence is not located in Culpeper, Fauquier, Madison, Orange or Rappahannock counties we CANNOT vaccinate you at this time. Please search for your county health department and contact them to receive vaccine information***
We will be in touch with you when we have additional vaccine information and/or to schedule your vaccine appointment. The process to call you back for an appointment may take several weeks. Please be patient with us as we work to serve you.
I have read and understand that vaccine may not available to me for several weeks.
I understand that this survey response does not schedule an appointment for me and that it may take several weeks to receive a call back for an appointment.
I understand that I must be at least 18 years or older to receive a vaccine even if I have an underlying health condition
Please select which category BEST describes your situation.
I am 75 years old or older
I am 65 to 74 years of age
I have an underlying health condition
Select which locality you live in. If you do not live in one of the below localities please do not complete this form. Please contact your local health department for more information.
First name of person to vaccinate. (one per survey, please)
Last name of person to vaccinate.
Date of Birth
Phone Number (this is required to schedule your appointment when its your time)
FULL Physical Address of person to vaccinate.
Other pertinent information you wish to provide
Thank you for submitting to us your vaccine interest. We will be in touch with you when we have additional vaccine information and/or to schedule your vaccine appointment. The process to call you back for an appointment may take several weeks. Please be patient with us as we work to serve you.
A copy of your responses will be emailed to the address you provided.
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This form was created inside of Commonwealth of Virginia.