Horizon Health Care COVID-19 Vaccine Sign-Up

Request an appointment to receive the COVID vaccine or booster dose at a Horizon Health Care clinic of your choice. After you complete the form below, you will be contacted by the clinic of your choice to finalize vaccination appointment scheduling. This may take up to 3-5 days.

COVID-19 Vaccine Appointment Request

Name*
First Middle Last
Sex*
- Female
- Male
- Unknown
Date of Birth*
MM slash DD slash YYYY
Phone*
Email*
Address*
Street Address Address Line 2 City State ZIP Code
What group do you fall in?*
Preferred Location To Receive Vaccine*
Please do not register more than one time, additional registrations do not change your position on the list. If you need to make a location change you will be able to do so once you are contacted by our scheduling teams.
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Horizon Health Care COVID-19 Vaccine Sign-Up

COVID-19 Vaccine Appointment Request

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