COVID Vaccination Registration - Hot Springs County Wyoming

Register - COVID-19 Vaccination List

Complete the below form to register for the Hot Springs County COVID-19 vaccine waiting list. This list is only for vaccinations that will be administered in Thermopolis, Hot Springs County, Wyoming.

Do you request to be vaccinated in Thermopolis, Wyoming?
Are you over age 18, or a parent/guardian of a child over age 12?

Once registered you will be contacted by Hot Springs County Public Health or Red Rock Family Practice to book your appointment. If possible, please print and complete the Vaccine Consent Form to the right and bring to your appointment. Forms are also available in the alcove at Hot Springs County Public Health, 117 N.4th Street. Please wear short sleeves to your appointment.

SECTION A

Vaccine preference: No preference Moderna Johnson & Johnson (Janssen) Pfizer (age 12 and older)

Name

Date of Birth

Phone

Address

Section B:

Complete this section in addition to the above only if you are requesting the Pfizer COVID vaccine for a child aged 12-17.

Parent/Guardian name - (please accompany your child to the appointment)

Parent/Guardian phone

Age of child today

Human Test

	COVID Vaccine Consent Form 588 Downloads	312.78 KB
	What to expect from your COVID vaccine 263 Downloads	199 KB
	Vaccine fact sheet-MODERNA 236 Downloads	143.95 KB
	Notice of Privacy Statement 110 Downloads	199.5 KB
	Consent Form Instructions 186 Downloads	40.59 KB
	Johnson & Johnson (Janssen) COVID-19 Vaccine Fact Sheet - NEW 4-27-21 124 Downloads	242.18 KB
	Pfizer BioNTech COVID-19 Vaccine Fact Sheet for Recipients and Caregivers 17 Downloads	154.84 KB

	Order 2 27th Continuation Revocation 27 Downloads	48.63 KB
	Order 1 27th Continuation Amended 36 Downloads	342.38 KB