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COVID-19 Vaccination Interest Form


Livingston County Health Department (LCHD) is administering COVID-19 vaccine to individuals who work or live within Livingston County, Michigan based on priority groups determined by MDHHS and subject to vaccine availability. This form will help us determine the Phase and Priority Group for individuals to receive the vaccine, and collect contact information. Please only complete this form once per person. LCHD staff will notify you using the contact information provided when we are able to schedule you for COVID-19 vaccination.

Please complete this form in its entirety and answer all questions on each page. To proceed to the next page, click the 'Next >' button at the bottom of this page.

Healthcare workers who are employed at hospitals or health systems should seek the vaccine through your employer, and not use this form.
Do you live or work in Livingston County, Michigan? *This question is required.