COVID-19 Vaccine Notification Request
The state of Wisconsin determines who is eligible for vaccines and at what time. Pierce County Public Health coordinates with local vaccinators and provides vaccines for those who cannot access vaccine through their healthcare provider. We cannot vaccinate people who are not part of populations approved by WI DHS.

Adults 65 years and older in Wisconsin will be eligible for the COVID-19 vaccine beginning January 25. Currently, frontline health care workers, residents in long-term care facilities (nursing homes and assisted living facilities), and police and fire personnel are eligible. There are approximately 700,000 Wisconsinites who are 65 and older and Wisconsin currently receives around 70,000 first-dose vaccines per week from the federal government. It will take months to vaccinate this population in Wisconsin.

THIS FORM IS NOT A WAITING LIST. However, if you are 65 years of age or older and would like to be placed on a list to receive information when appointments may be available through the county, please complete this form.

Remember, it will take months to vaccinate everyone 65 years or older in Pierce County. Before making an appointment with Pierce County Public Health, please reach out to your doctor to see if they are able to vaccinate you.
Note: If you are completing this on behalf of a family member, enter details as if you are them
Name (First and Last): *
Date of Birth (must be age 65 and older) *
Primary email address
Primary phone number to reach you at *
County of Residence *
Your street address *
Your city *
Your zip code *
Please understand vaccine supplies is limited. Vaccinating every person who wants a vaccine will take months.

Filling out this form WILL NOT guarantee you an appointment. It simply puts you on a list for contacts to receive vaccine information.

When you click submit, you are consenting to having the data you supplied collected and stored.

Thank you on behalf of Pierce County Public Health
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