COVID-19 Vaccine Sign-up

At this time the Alexander County Health Department is scheduling appointments for the Pfizer vaccine for persons age 12 and older and the Moderna vaccine for persons age 18 and older as well as booster appointments for those who are eligible. We are also accepting registrations for future appointments for pediatric Pfizer vaccine for those age 5-11.

If you would like to register for the vaccine, please complete this form and we will contact you as soon as possible.

Patient’s Name*
First Last
Patient’s Date of Birth*
Name of Person to Contact (if different than Patient)
First Last
Relationship to Patient
Phone Number*
PLEASE READ! DO NOT include +1 with your phone number.
Email
Address
Street Address City State ZIP Code
Dose number registereing for:
- First Dose
- Second Dose
- Third Dose/Immunocompromised
- Booster
Which vaccine are you registering for?
- Pfizer
- Moderna
- Janssen/J&J
Comment/Additional Info.
Comments
This field is for validation purposes and should be left unchanged.