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COVID-19 Vaccine Appointment Registration
PORT TOWNSEND, WASHINGTON
Jefferson Healthcare is offering vaccine appointments to residents of Jefferson County or those who live elsewhere and work in Jefferson County, Washington.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
**The Moderna vaccine can be give to individuals as young as 18 years old. If you are 16 or 17, please contact vaccineresponse@jeffersonhealthcare.org for more information.
Phone Number
*
Please enter a valid phone number.
Email
Mailing Address
*
Street Address or PO Box
Street Address Line 2
City
State (WA State residents only)
Zip Code
State
*
Please Select
Washington State
Other
Gender
*
Please Select
Male
Female
Other
Unknown
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In the last 14 days, have you tested positive for COVID-19?
*
Yes
No
In the last 14 days, have you had exposure (without proper PPE) to anyone who tested positive for COVID-19?
*
Yes
No
Have you had a new onset of fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting or diarrhea?
*
Yes
No
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You are not able to schedule an appointment at this time.
You are: not located in Washington State, or you have recently tested positive, had exposure to COVID or have a new onset of symptoms. You can contact the Jefferson Healthcare Respiratory Clinic for more information at 360-344-3094.
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Have you previously had a severe allergic reaction/anaphylaxis after receiving a vaccine or other injected medication?
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Yes
No
If you have had an immediate allergic reaction - even if it was not severe - to a vaccine or injectable medication, ask your doctor if you should get a COVID-19 vaccine before you make an appointment.
Have you received another vaccine (COVID-19 or any other vaccine) within the last 14 days?
*
Yes
No
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You are not eligible to receive the COVID-19 vaccine if you have received any other vaccine within the last 14 days.
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The vaccine requires two doses. Moderna doses must be spaced 4 weeks apart. Please select one option below. On the next page, you will choose one appointment time that will be applied to both dates.
*
Moderna: First dose on April 14 and second dose on May 12
Moderna: First dose on April 16 and second dose on May 14
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Please select one time below for your first dose.
We will automatically schedule your second dose at the same time.
Apr 7 and May 5 : Moderna
*
Apr 8 and May 6 : Moderna
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Apr 14 and May 12 : Moderna
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Apr 16 and May 14 : Moderna
*
Appt in Epic
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Working on it
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All immunizations will occur by appointment only at the Jefferson Healthcare Drive-Thru Immunization Clinic located on 7th & Cleveland Street behind the Manresa Castle.
Please click Submit to complete your response.
Please verify that you are human
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