This form is only an option for individuals interested in receiving the COVID-19 vaccine from an SCL Health location in the Denver Metro Area.

Our Montana hospitals and St. Mary’s Medical Center in Western Colorado are working with partners in their communities to administer the COVID-19 vaccine and will not use this form. See our COVID-19 Vaccine page for how to access a vaccine in those regions.


The quickest way to receive your COVID-19 vaccine is through SCL Health’s MyChart.

If you have an SCL Health MyChart account and are in an eligible vaccination group, you can log in to MyChart to self-schedule your vaccine. If you do not find an available appointment right away, please continue to check back frequently. You may also receive updates through the MyChart app and by email about vaccine availability.

If you do not have an SCL Health MyChart account, you can quickly create an account through our website. Please note, you do not have to be an SCL Health patient to create a MyChart account.

Schedule a Vaccine in MyChart

If you are unable to set up an SCL Health MyChart account, please continue to use the form below to be notified when an appointment for the COVID-19 vaccine is available for you. Appointments will only be available for individuals who are eligible for vaccination based on state guidelines, and outreach will be randomized and equitable. 

Please only fill out one submission per person.

The number of appointments available will depend on the amount of vaccine we receive, and it may take several weeks to work through each phase of vaccination eligibility. As previously mentioned, the quickest way to receive a vaccine is to set up or use a MyChart account.

Vaccine supply is managed by our partners at the Colorado Department of Public Health and Environment and the Montana Department of Health and Environment, and SCL Health is in constant communication with them to understand how much vaccine we can anticipate each week, and open up vaccination appointments accordingly.

If you have questions about the vaccine, including when you should get the vaccine or any health concerns or risks, please contact your primary care provider. If you do not have a primary care provider, now is the perfect time to get one. Visit doctors.sclhealth.org to find an SCL Health Medical Group family medicine, internal medicine, pediatrics or primary care specialist.

All fields marked with * are required.

*First Name:

*Last Name:

Email: (leave blank if you don't have an email address)

*Mobile Phone:

Other Phone:

*Date of Birth (mm/dd/yyyy):

*Age:

*Street:

*City:

*State:

*Postal Code:

*County of Residence:

*Have you been seen at an SCL Health clinic or facility in the last 2 years?  


 

*Please indicate if you are currently employed as any of the following (select one):






-Restaurant and food service workers that do not work in grocery or agriculture
-Manufacturing workers
-US postal service
-Public health and human services
-Faith leaders
-Providers of direct care for Coloradans experiencing homelessness
-Essential journalists
-Workers essential to the continuation of operations for state and local government
-Student-facing higher education employees
-Public transit and specialized transportation

*Have you been diagnosed with two or more of the conditions listed below?

-Cancer (receiving treatment within the last month)
-Chronic kidney disease
-COPD
-Diabetes mellitus (type 1 and 2)
-Down Syndrome
-Specific heart conditions (heart failure, cardiomyopathies, coronary heart disease, severe valvular/congenital heart disease)
-Obesity (BMI >30kg/m2)
-Pregnancy
-Sickle cell disease
-Solid organ transplant
-Individuals with disabilities who require direct care in their home
-People with disabilities that prevent them from wearing masks


 

*Have you been diagnosed with one or more of the conditions listed below?

-Asthma
-Cerebrovascular disease
-Cystic fibrosis
-High blood pressure
-HIV
-Neurologic conditions (such as dementia)
-Liver disease
-Pulmonary fibrosis (having damaged or scarred lung tissues)
-Thalassemia
-Adults who received a placebo during a COVID-19 clinical trial
-Use of corticosteroids or other immune weakening medicines
-Immunocompromised state from blood or bone marrow transplant
-Immune deficiencies


 

*We are managing a "rapid on-call list" to fill any cancellations. To be on this list, you must live within 15 minutes of a vaccination site and be willing to report to the site for vaccination within 15 minutes if called. Please indicate if you meet the criteria for the rapid on-call list and select the appropriate site below.

Yes, I want to be called and live within 15 minutes of one of these care sites:

*What is your preferred site (in your state) to receive the vaccination?

*Are you willing to be scheduled at the first available site?  


 


SCL Health does not guarantee notification within a certain period of time. If you do not include a valid email, you will not receive a confirmation email.

By clicking on the button below, I attest that my answers to these questions are accurate and I wish to be placed on the Notification List.

 

 

 

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