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Vaccination Request Form

  1. 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.
  2. My Age*
  3. Are You Requesting a 2nd or Booster Dose Appointment?*

    (For those who meet CDC criteria)

  4. Are You Willing and Able to Travel to Any Vaccination Site Within Lake County?*
  5. What Vaccine Clinic Sites Are You Able to Travel to on Short Notice?*

    (30 minutes or less)

  6. (Please do not include medical information.)

  7. Leave This Blank:

  8. This field is not part of the form submission.