COVID-19 Vaccine Screening Questionnaire
You must complete the questionnaire below to verify you are eligible for vaccination at this time. These POD’s are operated by the respective provider, questions regarding appointments can be directed to the provider.
Note - Enrolling in multiple appointments at multiple sites will void your appointments. Please enroll in only 1 appointment.
Note - Only the Pfizer vaccine has been approved for those who are 12 years of age and older.
I attest that I am at least 12 years of age and either live or work in the state of Illinois. (Note: Only the Pfizer vaccine has been approved for those who are 12 years of age or older.)
I authorize IDPH to send me appointment reminders and notify me of my COVID-19 vaccine appointments at the provided email address and phone number. Message and data rates may apply.