COVID-19 Vaccine Interest Form

Covid Vaccine Interest Form

At Delhi Hospital & Clinics, the safety & health of our community is a vital part of our mission. We are proud to help lead the way out of the pandemic by offering COVID-19 vaccines, close-to-home at the Delhi Rural Health Clinic. If you are interested in receiving your COVID-19 vaccine, please complete the form below and we will contact you to schedule your appointment.

We will be following the state's outlined phases and administering vaccines to those who qualify within the current phase. At this time, Moderna vaccines are approved for those 18 and older. 

If you have any questions or would like more information, contact our COVID-19 Vaccine Coordinator at (318) 878-6238.















 Patient
 Caregiver/Family Member

*If you are a Caregiver/Family Member completing this form, please fill out the information below: