COVID - 19 Vaccination- Vaccination Form

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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

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 preexisting conditions that increase your risk for severe COVID-19 illness? (Including but not limited to diabetes, obesity, chronic kidney disease, cancer, COPD, pregnant)?*
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.