PSMC COVID-19 Vaccine Reservation Form
Thank you for accessing the reservation for the COVID 19 vaccine waiting list. If you are a person 70 years of age or older living in Archuleta County and you wish to receive a vaccine as vaccine is made available to PSMC, you need to read and complete the following COVID-19 Vaccine Reservation forms. The supply of COVID-19 vaccine is limited, so please be patient as you wait to be contacted. PSMC follows the State of Colorado’s vaccine distribution plan. The vaccine phased distribution will take several months to complete.

Please read the information on the “Factsheet for Recipients” and the “Should I Get A COVID 19 Vaccine”.

After you have read the information, please complete the “Adult Demographic” section. You will need to complete and sign the “Consent Form” when you present to receive your vaccine. A link to this Consent Form is provided at the end of this online form, you will be asked to Indicate what vaccine group you are a part of and choose SUBMIT when you are finished.

Once you complete this online form, you will be placed on the waiting list and we will contact you to confirm your reservation.

Once we receive vaccine for your group we will contact you to make an appointment for you to receive the vaccine.

PLEASE NOTE: Any information you provide below is being transmitted and stored following all HIPAA Regulations. The sole purpose for gathering this information is to enable the reservation of patients to distribute the COVID-19 Vaccine.

PLEASE PROVIDE YOUR EMAIL ADDRESS BELOW TO RECEIVE A CONFIRMATION EMAIL CONTAINING YOUR RESPONSES. THANK YOU
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