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. 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
Name of Person to Contact (if different than Patient)
First Last
Relationship to Patient
Phone Number*
Area code and phone number only. 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
Disclaimer
*For those registering for a third dose, please note that – at this time – a third dose of Pfizer or Moderna is only authorized for moderately to severely immunocompromised persons such as those with the conditions listed below.
(Boosters shots for those who are not moderately to severely immunocompromised have not been authorized at this time. We expect to know more in the coming weeks about when/how these doses may be made available and we will notify our community when we are able to begin giving those vaccines.)
Third doses are to be from the same manufacturer as your first and second doses unless there is not availability of that vaccine at the time of your third dose. In that case, you may receive a dose of the other mRNA vaccine. There is no recommendation for additional doses of the Jansen/J&J vaccine at this time.
If you are registering for a third dose of Covid-19 vaccine, do you attest that you:
- Are moderately to severely immunocompromised and have one of the following conditions (You do not need to indicate which condition(s) you have.)
- Been receiving active cancer treatment for tumors or cancers of the blood
- Received an organ transplant and are taking medicine to suppress the immune system
- Received a stem cell transplant within the last 2 years or are taking medicine to suppress the immune system
- Moderate or severe primary immunodeficiency (such as DiGeorge syndrome, Wiskott-Aldrich syndrome)
- Advanced or untreated HIV infection
- Active treatment with high-dose corticosteroids or other drugs that may suppress your immune response
- And you have talked to your healthcare provider about our medical condition(s) above and are requesting the third dose of Covid-19 vaccine based on his/her recommendation?
Agree to disclaimer
- Yes
- No
Which vaccine did you receive for your first two doses:
- Pfizer
- Moderna
Comment/Additional Info.
Phone
This field is for validation purposes and should be left unchanged.

Disclaimer