Pre-Register NOW for the COVID-19 Vaccine

Pre-registration is now available for the COVID-19 vaccine. The vaccine is now open those described below. Please scroll down to complete the pre-registration form.

Phase 1B, Tier 1

  • Individuals 65 & older
  • Healthcare personnel with direct patient contact
  • Individuals deemed extremely vulnerable to COVID-19
  • Long-term care facility residents & staff
  • Essential employees working in the following categories: First responders, Corrections, Food & Agriculture, U.S. Postal Service, Manufacturing, Grocery Stores, Public Transit, Education (*including teachers & support staff), Childcare Workers

*Winterset, I-35 & Earlham school employees must work with school administration on receiving vaccinations.

Phase 1B, Tier 2

  • Frontline essential workers in food, agriculture, distribution, and manufacturing sectors who live or work in non-social distanced settings
  • Individuals with disabilities living in home settings and their direct care staff

Phase 1B, Tier 3

  • Staff and individuals living in congregate settings not covered by previous Phase or Tier
  • Government officials, including staff, engaged in business at the State Capitol

Phase 1B, Tier 4

  • Inspectors responsible for health, life and safety

Phase 1B, Tier 5

  • Correctional facility staff and individuals incarcerated

Phase 1C

  • Persons aged 16-64 years with medical conditions that increase the risk for severe COVID-19, and essential workers not previously included in Phase 1A or 1B

Please complete and submit this form below in order for us to identify those who would like to receive the vaccine. Please take note, there is limited vaccine supply.  We will be in touch with you to schedule an appointment.

Please Be Patient…

Limited Vaccine Supply

We currently have a limited supply of COVID-19 vaccines. Please be patient as we work to administer the allotted supply. If you have submitted a Pre-Registration form, we will put you on our waiting list – there is no additional need to contact our clinic to confirm your place. We will reach out to those on our list as supply and appointments become available.

COVID-19 Vaccine Registration & Acknowledgement Form

Please fill out, print and sign the registration and acknowledgement form below to bring with you to your appointment. One registration form per person needing a COVID-19 vaccine administered. 

Patient Registration & Acknowledgement - COVID-19 Vaccine

Our ER, Urgent Care, and Clinics are open to patients. Urgent Care please call first. For More Information CLICK HERE