Name: | DOB: | MRN: | PCP:

I am interested in a COVID-19 Vaccine

Please review the listing available on the previous page to determine your eligibility to receive the COVID-19 vaccine. If eligible, complete the form below to be put on a callback list for a COVID-19 vaccine appointment.

Eligible community members who request appointments will be contacted by Aspirus schedulers as closely as possible to the order in which requests are received.

Callbacks

You will not receive a call immediately upon submitting your request. The timing of callbacks and appointment availability will vary due to eligibility, demand, location, and vaccine supply. We thank you for your patience during this process.

Due to patient privacy regulations, some phone carriers may display calls from Aspirus as UNKNOWN or PRIVATE on a caller-ID. If you miss our call-back, we will try again a second time.

Other Considerations

    • Educators and Childcare Providers – Your vaccinations are being coordinated through public health. Your employer should work directly with your local health department to determine when and where you may be able to get vaccinated. Do not fill out this form unless you are excluded from the process through public health, such as educators at institutions of higher learning.
    • Michigan Essential Workers – Contact your local public health department.
    • Wisconsin Phase 1B Information.

Registration Information
*indicates required field
Where do you live? *
Gender: *

Educators and Childcare Providers – Your vaccinations are being coordinated through public health. Your employer should work directly with your local health department to determine when and where you may be able to get vaccinated. Do not fill out this form unless you are excluded from the process through public health, such as educators at institutions of higher learning.

To provide better service to you, ongoing updates may be sent to the email address you provided until you are able to be scheduled for vaccination. An opt-out will be included if you do not wish to receive further email communications.


Press submit only once to avoid multiple submissions and allow the site a few moments to process your information.