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. 

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.

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:







*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):







*Please indicate if you have been diagnosed with any of the conditions listed. Please choose one option.





*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?  


 


If you do not include a valid email, you will not receive a confirmation email.

 

 

 

 

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