Vaccination Appointment Form

Complete the Vaccination Appointment Form below. We will contact you with your scheduled day and time. Thank you for choosing Labette Health!

*First name:

*Last name:

*Date of birth

*Phone Number

*Address

*City

*State

*Zip

Choose to be vaccinated at one of our upcoming events OR at your preferred clinic location.

*Hospital Employees: Skip down to the Employee Check Box

Upcoming Vaccine Events

Preferred Location

Preferred Day

Any Monday Tuesday Wednesday Thursday Friday Saturday Sunday

I'm a Labette Health Employee

*Is this your...

First Dose Second Dose

Comments/Additional Info:

*I attest that I am eligible to receive a COVID-19 vaccination under the vaccine distribution guidelines of the Kansas Department of Health and Environment.

Submit