COVID-19 Vaccine Interest Form

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The Philadelphia Department of Public Health is working to roll-out vaccine to Philadelphia Residents in a Phased Approach. The purpose of this form is to gather information from individual Philadelphia Residents about their interest in receiving COVID-19 vaccination within Philadelphia County.

We will ask some questions to determine when you are able to get the COVID-19 vaccine. The information entered on this form will be kept confidential with the Philadelphia Department of Public Health and will only be used to connect you with where you can register to receive a COVID-19 vaccine in the near future.

Note:  The above descriptive information came from the program's home page.

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