Unfortunately, there is not enough vaccine in the city right now for everyone who wants it. So the Health Department needs to make sure that people who are at the highest risk from COVID can get access to it first. This form will let the Health Department know that you are interested in receiving the COVID-19 vaccine, and make sure that people with the highest risk can get it first. If you cannot complete this form, call 311 or (215) 685-5488 or email covid@phila.gov.

COVID-19 Vaccine Interest Form (phila.gov)