COVAX Interest Forms

Appointments are opening regularly, eligible Baltimore City residents are encouraged to fill out a form below!


Currently, the Baltimore City Health Department Offers three Vaccination Interest Forms for

  • Baltimore City Older Adults Aged 60 and up 
  • Baltimore City residents with Intellectual or Developmental Disabilities
  • Baltimore City residents aged 16 through 59, interested in pre-registering for vaccination appointments, once they are available.* 

These forms are NOT registration for COVID-19 vaccination. Please complete these forms so the Health Department can contact you when we have vaccination appointments available. Please complete a separate form for each person who is interested in receiving the vaccine and is in this category.

By completing and submitting this form, you are giving the Baltimore City Health Department permission to share your contact information with a healthcare provider. If you have questions, please email us at [email protected].

 

 

*The Baltimore City Health Department is following the Maryland Department of Health’s vaccination prioritization guidelines, and while COVID-19 vaccine supply is still limited, Maryland is prioritizing vaccines based on recipients' relative risk of exposure or developing a serious illness. However, the form below can be used by any Baltimore City residents interested in receiving a vaccination. By April 27th, all Marylanders aged 16 and up will be eligible for a vaccination. Once vaccine supply increases, our team will reach out to contact you with the details of your appointment.