COVID-19 Vaccine Interest Form
Please complete this form if you are interested in receiving a COVID-19 vaccine. When we reach your priority group and vaccine is available, Allegany County Health Department or UPMC Western Maryland will contact you by email or phone to schedule a vaccination appointment.

Completing this form does NOT make you an appointment to be vaccinated. It may take several weeks, or longer, until you are contacted to schedule an appointment because of limited vaccine supply.
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Name *
Age *
City or town *
Email address (enter "none" if you have no email) *
Phone number *
Do any of these apply? *
Do you have one or more of the following health conditions: cancer, cardiomyopathies, chronic kidney disease, COPD, coronary artery disease, Down syndrome, heart failure, obesity (body mass index over 30), organ transplant, pregnancy, sickle cell disease, smoking, Type 2 diabetes? *
I am employed in one of the following fields: *
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