JCHD COVID-19 Vaccine Request Pre-Registration Form
THIS IS NOT AN AUTOMATIC APPOINTMENT!
Thank you for your interest in receiving the COVID-19 vaccine!
The JCHD will gradually make its way through the Phases listed below (beginning with Phase1a and ending with Phase 4), as vaccine supply and demand allows. Completing the following vaccine request form will help JCHD determine your phase eligibility and capture required pre-registration contact information.
JCHD will inform the public of which phase we are currently vaccinating on our website at
or through our Facebook page -
. When your phase becomes active, you will be notified via email when you are able to schedule an appointment.
COVID-19 Vaccine Information
KY Dept. for Public Health COVID-19 Vaccine Frequently Asked Questions:
CDC's frequently asked questions about COVID-19 Vaccination:
To learn more about the Moderna COVID-19 vaccine, please visit:
Kentucky Department for Public Health - Vaccine Phases Description
This information remains confidential. Make sure to provide accurate information, as our staff will need that information to contact you to schedule an appointment at a later date. We estimate that we will begin Phase 1b vaccines in early February and then phases 1c, 2,3 & 4 will follow. JCHD will maintain a list of individuals to be vaccinated. Again, THIS IS NOT AN APPOINTMENT! PRE-REGISTER WILL ONLY PLACE YOU ON A WAITING LIST BASED ON YOUR PHASE ELIGIBILITY.
Note: JCHD offers the Moderna vaccine which is currently only approved for individuals 18 years of age or older.
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