Vaccine Waiting List - Johnson Memorial Health Services

If you are a current JMHS patient and/or a resident of Minnesota, please fill out the form below to be added to our waiting list. Please note at this time we are only allowed to give COVID-19 Vaccines to State residents.

Waiting List

Name*
First Last
Date of Birth*
Please use this format: mm/dd/yyyy
Age*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Enter Email Confirm Email
Health Conditions or Risk Factors
Occupation*
Are you currently or have you been a patient at JMHS?*
- Yes, within 18 months
- Yes, within 5 years
- No
Please note that MDH rules have changed and patient status doesn't determine access to vaccine. This information is used to help with vaccine administration only.
Email
This field is for validation purposes and should be left unchanged.