COVID-19 Vaccination Information

Thank you for your interest in the COVID-19 vaccination.

Please complete the form below to register to receive the vaccine for COVID-19.

Documentation required for minors (ages 12-17) receiving the Covid-19 vaccine:

  • Parents/Legal Guardians bringing minor must present a valid form of ID (driver’s license) at the time of vaccine
  • Notarized written consent in cases where the parent/guardian is not present at the time of vaccination
    • Parents may also call 502-SHOT to give verbal consent before vaccination if unable to provide written documentation
  • Notarized Affidavit (link below)
  • Letter of written consent by Children’s Division, or designee, for all minors under the care of Department of Social Services/Division of Youth Services
  • Documentation of proof if pregnant/married/emancipated minor
  • Documentation from person/entities, such as governmental or nonprofit agency, if the youth is homeless

Click the link below to access the Affidavit form. The form can be completed online, then printed.

Minor Consent Form

A third booster shot of the Pfizer vaccine may be administered 6 months after completion of the Pfizer series. It is approved for only people ages 18 and older, and is limited to the following criteria:

Advanced age 65+ Age only
Long-Term Care residents 18 years and up Resident of long-term care facility
Patients with underlying medical conditions 18-64
  • Cancer or history of
  • Chronic Kidney Disease
  • Chronic Lung diseases (i.e., COPD, asthma)
  • Dementia or other neurological conditions
  • Diabetes (1 or 2)
  • Down Syndrome
  • Heart Disease (i.e., high blood pressure)
  • HIV Infection
  • Immunocompromised state
  • Liver disease
  • Overweight (BMI >25)
  • Pregnancy/recently pregnant
  • Sickle Cell disease or Thalassemia
  • Smoking, current or former
  • Solid organ or blood stem cell transplant
  • Stroke
  • Substance use disorders
Patients with increased risk for COVID-19 exposure due to occupational or institutional setting 18-64
  • First responders (healthcare workers, firefighters, police, congregate care staff)
  • Education staff (teachers, support staff, daycare workers)
  • Food and agriculture workers
  • Manufacturing workers
  • Correction workers
  • U.S. Postal Service workers
  • Public transit workers
  • Grocery store workers

*** If registering for the booster vaccine, please bring your Covid Vaccination Card with you to your appointment. ***

Registration Form

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By providing my phone number and/or email address, I opt-in to receive SMS messages and/or Emails from Freeman Health System.

If you have any questions, please call 417-502-SHOT (7468).