City of Moundville

City of Moundville

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HCH COVID-19 Vaccine Interest Form

Hale County Hospital is collecting information for all people who are interested in the COVID vaccine. We DO NOT know when we will receive vaccines. Please fill out all the following information for the person who would like to receive the vaccine and we will get back to you as soon as we have vaccines on hand.

*FILLING OUT THIS FORM DOES NOT GUARANTEE YOU HAVE AN APPOINTMENT OR THAT YOU WILL RECEIVE THE VACCINE*

PLEASE CLICK LINK BELOW**

https://docs.google.com/forms/d/e/1FAIpQLSdxahy_Od2LyYY3NKQRuZl0F0cGVlcsZk_Jm8E-OJgtDjZ5Jg/viewform