Smith County COVID-19 Vaccine Request Form

Please complete the below form to be added to the county’s vaccination list. This will put you on the list with the clinic and the health department. This form should also be used by those who would like to request a booster dose (3rd dose) of mRNA vaccine (Pfizer or Moderna). This webpage is no longer support by Internet Explorer. Please use Chrome, Firefox or Edge to complete the employment application. You may download one of these browsers at the link provided.

To receive confirmation of your request, please include an email address or watch the screen for a confirmation message after you’ve submitted your request. When vaccine becomes available for the general public, we will begin contacting residents based on this list.

We do not know when the vaccine will be available and are working regularly with state officials to plan and prepare for vaccinating the general public. As we know more, we will be sharing information through the local newspaper and social media outlets.

Learn more about the statewide vaccination prioritization plan or the COVID-19 vaccine.