Grays Harbor County COVID-19 Vaccine Intake Form

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This form is to register with Grays Harbor County Public Health and Human Services for a COVID-19 Vaccination.

Please only use this form if you intended to receive a COVID-19 vaccination for Grays Harbor County Public Health.

Please do not use this form if you have already received your vaccine.

This form is not for scheduling your vaccination. Rather, this will gather your information and place you in a Phase according to the Washington State Department of Health's Vaccine Phases. You will be contacted by our Resource Center once it is time to schedule your vaccination.

If you need technical assistance or have any questions regarding this form, please call our Resource Center at (360) 964-1850 Mon-Fri 8:30 AM - 4:00 PM, Sat, Sun, and Holidays 10:00 AM - 2:00 PM PST.

First Name *

Middle Name

Last Name *

Date of Birth *

YYYY

Email Address *

Phone Number *

Are you a resident of Grays Harbor County? *

Yes

If yes, have you ever had an adverse reaction to an immunization? Such as anaphylactic response?

Yes

Not sure

Clear selection

Have you had a COVID-19 Diagnosis? *

Yes

If yes, when was your diagnosis? (Or best guess)

YYYY

Would you like to receive the vaccine when it is available for your eligibility group? *

Yes

I would like more information.

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