Vaccine Interest Form
Completing this form does NOT make you an appointment to get the vaccine.
You only need to complete the form once.
It will take several weeks or longer until you are contacted to schedule an appointment, since it depends on vaccine availability.

We will be communicating updates regarding vaccination in the County Joint Information Center (JIC) Briefings on Tuesdays, and Fridays. Please sign up to receive these updates by going to https://www.washco-md.net/pr-marketing/email-notification-sign-up/ and check off general county on the email list.
Email address *
Full Name (First, Middle, Last) *
Phone Number *
Current Age
Phase 1a-c, 2a priority groups
If you received the COVID-19 vaccine from a different provider and want to remove your name from our contact list, you are able to edit your previous chosen priority group to Already vaccinated . . . . .
Priority Group *
Employer name/organization name *
County of Residence *
Preferred language *
If you can be at one of our clinics within 30 minutes you can be placed on a "quick call" list to be notified if there are last minute cancellations. Would you like to be placed on this list?
A copy of your responses will be emailed to the address you provided.
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