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Holy Rosary Healthcare, St. James Healthcare, St. Vincent Healthcare, and St. Mary’s Medical Center will not be participating in this form. See our COVID-19 Vaccine page for how to access a vaccine in those regions.
All fields marked with * are required.
Please fill out 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.
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.
Vaccine supply is managed by our partners at the Colorado Department of Public Health and Environment and the Montana Department of Health and Human Services, 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.
To help evaluate when you should get a vaccine or if you have any health risk factors that may require you to receive a vaccine in an earlier phase, please work with 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.
*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:
*Please indicate your race:
American Indican Asian African American Hispanic Native Hawaiian or Other Pacific Islander Caucasion/White Prefer not to answer
*Have you been seen at an SCL Health clinic or facility in the last 2 years?
Yes No
*Please indicate if you are currently employed as any of the following (select one):
Healthcare worker Long-term care or assisted living facility worker Firefighter, police, COVID-19 response personnel, correctional worker, funeral services Child care worker in licensed child care programs; Pre K-12 teacher (full-time and substitutes), bus, food, counselors, administrative, safety and other support services offered inside the school; or Member of the Executive and Judicial branches of state government. Frontline essential worker (education/teacher, food and agriculture, manufacturing, US postal service, public transit and specialized transportation staff, grocery, public health, frontline essential human services worker, faith leader, direct care provider for those experiencing homelessness, essential frontline journalist, or essential state official in executive, legislative, or judicial branches of government) Other essential worker as designated by government officials (examples may include those working in energy, water, construction or local government) I am not employed in any of the professions listed above
*Please indicate if you have been diagnosed with any of the conditions listed. Please choose one option.
Obesity, diabetes, cancer, chronic obstructive pulmonary disease (COPD), heart failure, cardiomyopathy, coronary artery disease, severe valvular/congenital heart disease, chronic kidney disease, or are immunocompromised Sickle cell disease or Down syndrome Cerebrovascular disease, cystic fibrosis, high blood pressure, neurologic conditions (such as dementia), liver disease, pulmonary fibrosis (having damaged or scarred lung tissues), asthma (moderate to severe), or thalassemia Currently pregnant None of the above
*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: Good Samaritan Medical Center Lutheran Medical Center Adams County Gov. Bldg. Saint Joseph Hospital No, I am not interested/able to be on the rapid on-call list
*What is your preferred site (in your state) to receive the vaccination?
CO-Adams County Gov. Bldg CO-Good Samaritan Medical Center CO-Lutheran Medical Center CO-Saint Joseph Hospital
*Are you willing to be scheduled at the first available site?
If you do not include a valid email, you will not receive a confirmation email.
