Pre-Register NOW for the COVID-19 Vaccine

Phase 1B – Tier 1

Pre-registration is now available for the COVID-19 vaccine. Eligible residents can save their place in line by completing the pre-registration form below.

  • 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.


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 & appointments become available.

COVID-19 Vaccine Registration & Acknowledgement Form

Please fill out, print and sign the registration & 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