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2. 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.

   • Contact and appointments may be last minute.
   • Please submit only one form per person.
   • Use this form for first or second doses, or booster doses for those who meet the criteria.
4. First Name*
5. Last Name*
6. Phone*
7. Email
9. My Age*

   1. 12 to 17 Years Old

   1. 18 Years or Older
10. City or Area of Residence or Work Location*
    -- Select One --Anderson SpringsBig ValleyBlue LakesClearlakeClearlake OaksClearlake ParkClearlake RivieraCobbFinleyGlenhavenHidden Valley LakeHighland SpringsKelseyvilleLake PillsburyLakeportLampson Airport AreaLoch LomondLower LakeLucerneMiddletownNiceNorth LakeportRiviera HeightsRiviera WestScotts ValleySpring ValleyUpper Lake
12. Are You Requesting a 2nd or Booster Dose Appointment?*

    1. No, I Have Not Been Vaccinated
    2. Yes, I Have Received a 1st Dose of Pfizer
    3. Yes, I Have Received a 1st Dose of Moderna
    4. Yes, but I'm Not Sure What Vaccine I Need
    5. Yes, I Meet Criteria for Booster or 3rd Dose

    (For those who meet CDC criteria)

14. Are You Willing and Able to Travel to Any Vaccination Site Within Lake County?*

    1. Yes, I Am Willing and Able to Travel to Any Vaccination Site Within Lake County
    2. No, I Am Not Willing and Able to Travel to Any Vaccination Site Within Lake County
    3. I Am Home-Bound and Would like to Be Contacted if Mobile Services Become Available
16. What Vaccine Clinic Sites Are You Able to Travel to on Short Notice?*

    (30 minutes or less)

    1. Lakeport
    2. Clearlake
    3. I Am Not Able to Travel to a Clinic Site on Short Notice
18. Is There Any Other Information We Should Know Before Scheduling Your Appointment?

    (Please do not include medical information.)

Leave This Blank:


20. 1. Receive an email copy of this form.
21. Email address

    This field is not part of the form submission.

22. Submit

* indicates a required field