COVID-19 Vaccine Contact Form

Please note:

When submitting the form, please be sure contact information, including name, phone number and email address, is accurate.
After this form has been submitted, we will contact you via email or phone to register for a vaccination clinic. When contacted, please make sure your health insurance information is easily accessible as it is required during the registration process. The vaccine itself is being provided at no cost by the federal government; insurance will be charged for the cost of administering the vaccination. Individuals will not be turned away for not having insurance.

Contact Information

First Name: (Required)

Last Name: (Required)

Email Address: (Required)

Email Address (Confirm):

Phone: (Required)

Street Address: (Required)

City: (Required)

COVID-19 Vaccine Priority Groups

Please use the menu below to select your priority group.

Phase 1A - Healthcare workers and first responders

Phase 1B - Older individuals, people with underlying health conditions, other congregate settings, child care workers, and employees of preschools and kindergarten through 12th grade

Phase 1C - Essential workers and people of any age at increased risk for COVID-19

Phase 2 - North Dakota residents over the age of 12. The age qualifier is due to authorization by the FDA for use of the vaccine in specific age groups.

The Pfizer-BioNTech vaccine is authorized for individuals 12 years and older
The Moderna and Johnson & Johnson vaccines are both authorized for individuals 18 years and older