Create a Website Account - Manage notification subscriptions, save form progress and more.
Please do not visit a clinic without an appointment.
This form is for Lake County residents and workers who need a COVID-19 vaccine. You must be 18 or older, or 12 to 17 with your parent's or legal guardian's consent. Adolescents 12 to 15 should check with their healthcare provider to see if they're offering the vaccine before submitting this form.
Lake County Public Health uses your information to contact you if there are leftover or unanticipated doses of vaccine, or if the vaccine you need is available.
(For those who meet CDC criteria)
(30 minutes or less)
(Please do not include medical information.)
This field is not part of the form submission.
* indicates a required field