COVID-19 Vaccine Interest Form

Covid Vaccine Interest Form

If you would like to be contacted when COVID-19 vaccines are available, please complete the form below.

Due to limited supply, vaccines will be distributed in phases and will be given to those who are most at risk first. This form will help Delhi Hospital & Clinics prepare by allowing us to track interest and plan for distribution as soon as vaccines arrive. We will be following the state's outlined phases and administering vaccines to those who qualify within the current phase. We will contact patients or their caregivers to schedule appointments based on eligibility and priority. Thank you for your patience.

If you have questions or issues with the form, contact us at (318) 878-6238.















 Patient
 Caregiver/Family Member

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