COVID - 19 Vaccination- Vaccination Form

Prince George's County

COVID Vaccination - Submit Health Information

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NOTE : Please Complete the COVID-19 Pre-Registration Form below to get on our vaccination wait-list. As appointments become available, individuals who complete and submit this pre-registration form and are eligible will receive an email from the Health Department with a link and instructions on how to make a vaccine appointment. COVID-19 vaccines are offered by appointment only.

COVID-19 vaccines are free for all residents who live and work in Prince George’s County regardless of insurance coverage or immigration status. Information provided during pre-registration will NOT be used by the federal, state or local government for any civil or criminal prosecution or enforcement, including, but not limited to, immigration enforcement. Your information will be private and protected. Providers and vaccination sites collect certain information from individuals receiving the vaccine to monitor how many people are receiving the vaccine and to ensure dose matching and appropriate timing for the second dose.

Personal Information

First Name: *

Middle Name:

Last Name: *

Address Line 1:*

Address Line 2 (Unit/Apt #): (Optional)

City:*

State:

Zip:*

Date Of Birth (MM/DD/YYYY) : *

Email Address:

Home Phone

Cell Phone

Race: * Asian
Black or African American
Native American
White
No Response
Other/Multiple (please specify)

Are you Hispanic or Latino?*
Yes
No
No Response

Opt-in for other county-related emergency updates.

Select Applicable Category

Verification will be required upon arrival to receive the vaccine

NOTE : If you are not an employee or resident in a frontline healthcare or public safety setting, click NO.

Are you an employee or resident in a frontline health care or public safety setting?*

Hospital and frontline health care workers
Residents and staff of long-term care facilities/nursing homes
Frontline first responders/essential public safety workers
All licensed, registered, and certified health care providers
Department of Corrections staff
Morticians, Undertakers, Funeral Directors
Court System (Frontline Judiciary Staff)

YES
NO

Do you have any disabilities and/or preexisting conditions that increase your risk for severe COVID-19 illness? YES
NO

Do you have an intellectual or developmental disability?*
YES
NO

NOTE : By clicking submit, you consent to being contacted by phone, text, and email when you will be eligible to schedule an appointment for COVID-19 vaccination.

list of eligible Conditions

Cancer
Chronic kidney disease
COPD (chronic obstructive pulmonary disease)
Down Syndrome
Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies
Immunocompromised state (weakened immune system) from solid organ transplant
Obesity (body mass index [BMI] of 30 kg/m2 or higher but < 40 kg/m2)
Severe Obesity (BMI ≥ 40 kg/m2)
Pregnancy
Sickle cell disease
Smoking
Type 2 diabetes mellitus
Asthma (moderate-to-severe)
Cerebrovascular disease (affects blood vessels and blood supply to the brain)
Cystic fibrosis
Hypertension or high blood pressure
Immunocompromised state (weakened immune system) from blood or bone marrow transplant, immune deficiencies, HIV, use of corticosteroids, or use of other immune weakening medicines
Neurologic conditions, such as dementia
Liver disease
Overweight (BMI > 25 kg/m2, but < 30 kg/m2)
Pulmonary fibrosis (having damaged or scarred lung tissues)
Thalassemia (a type of blood disorder)
Type 1 diabetes mellitus