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COVID-19 Vaccine Interest Form
COVID-19 Vaccine Interest Form
Submit your information below & be notified when it's your time to get vaccinated.
14Questions
COVID-19 Vaccine Interest Form
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    DISCLAIMER: By submitting this form you are granting Frederick Health permission to contact you via email and/or text message.

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    Please select one location from the following list.
    • Crestwood
    • Mount Airy
    • Myersville
    • Liberty
    • Internal Medicine Associates (IMA)
    • Walkersville
    • Urbana
    • Toll House
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  • 4
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    Message & data rates may apply.
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    Pick a Date
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  • 8

    IMPORTANT NOTE: To review a list of underlying medical conditions that could potentially increase your risk for severe COVID-19 illness, please visit the official CDC website.

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    Groups that are currently eligible to receive the vaccine:

    • All licensed, registered and certified health care providers
    • Front line hospital staff
    • Nursing home residents and staff
    • Individuals with intellectual and developmental disabilities
    • Assisted living, independent living, behavioral health and developmentally disabled group homes, and other congregate facilities
    • Law enforcement and firefighters, EMS
    • Education staff, including K-12 teachers, support staff and daycare providers
    • Correctional health care staff and officers
    • Public safety workers not covered in Phase 1A
    • Health care workers not covered in Phase 1A, including but not limited to lab services, public health, vaccine manufacturing and other health care professions
    • Front line judiciary staff
    • Continuity of government
    • Food/agriculture production, critical manufacturing, U.S. Postal Service, public mass transit, grocery store employees
    • Veterinarians and support staff
    • Clergy and other essential support for houses of worship
    • Adults age 60 and older
    • Individuals who are currently hospitalized AND diagnosed with the following criteria:
      • Cancer patients who are currently in active treatment
      • End stage renal disease patients requiring hemodialysis
      • Chronic Obstructive Pulmonary Disease (COPD), especially those who are
        • oxygen-dependent or are steroid dependent
        • Solid organ transplant recipients
        • Sickle cell disease patients
        • Diabetic patients (Type 1 and Type 2)
      • Individuals who are diagnosed with these medical conditions but are not currently hospitalized will be eligible to receive the vaccine in Maryland’s Phase 2 COVID-19 vaccine distribution.

    Click here to learn more.

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    All vaccinations are held at our Frederick Health Village location. CLICK HERE for directions.

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