NORTH Pacific County COVID-19 Vaccine Waitlist
Please only complete this form if you live or work in NORTH Pacific County AND you are currently eligible for the vaccine (currently that only includes those over 65, certain folks over 50 who live in multigenerational households, and people who work in a healthcare setting). All others will be deleted.

Completing this form puts you on the waitlist. Once we have vaccine and your number comes up, a provider in Pacific County will call you to schedule an appointment. Due to lack of vaccine supply, it may be several weeks before you receive a call. To find out what number you are on the waitlist, you can email us at info1@pacificcountyhealth.com
Last Name *
First Name *
Age *
Date of birth *
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Address *
City *
Zip code *
Phone *
Email address
Ethnicity *
Race *
Do you have a known history of a severe allergic reaction (e.g. anaphylaxis) to this vaccine or any components of the vaccine such as lipids, potassium chloride, monobasic potassium phosphate, sodium chloride, dibasic sodium phosphate dihydrate, and sucrose? *
In the past two weeks, have you tested positive for COVID-19? *
In the past 2 weeks, have you had exposure to a person who tested positive for COVID-19 at a distance of 6 feet or less for more than 15 minutes without personal protective equipment, such as masks? *
Have you had new onset of fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle/body aches, headache, new loss of taste/smell, sore throat, nausea, vomiting or diarrhea? *
In the past 90 days have you received passive antibody therapy as part of COVID-19 treatment? *
Are you pregnant or breastfeeding or do you plan to become pregnant? *
Are you immune compromised or on a medicine that affects your immune system? *
Do you have a bleeding disorder or are you on a blood thinner? *
Do you have a history of severe allergic reaction (anaphylaxis) to another vaccine or injectable medication? *
Have you received any other vaccinations in the past two weeks? *
Emergency contact name
Emergency contact phone number
What type of insurance do you have? *
If you have private insurance, what is the name of your insurance company?
If you have private insurance, what is your policy number?
Do you live in a multigenerational household? This means you live with and care for a younger relative who is not your own child OR you are not able to live independently and you have in-home care. *
Do you work in a healthcare setting? *
Do you live or work in Pacific County? *
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