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Vaccination Request Form

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 12-17 with your parent’s or legal guardian’s consent. Adolescents 12-15 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.

 

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My age is:
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Are you requesting a second dose appointment?
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Are you willing and able to travel to any vaccination site within Lake County?
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What vaccine clinic sites are you able to travel to on short notice? (30 minutes or less)