COVID-19 Vaccine Request

If you are interested in getting a COVID-19 vaccine through Southwell Health System, please fill out the vaccine request form. If you are not comfortable using the form, please call the COVID vaccine request line at 229-353-2200. IF YOU COMPLETE THE FORM PLEASE DO NOT CALL FOR AN APPOINTMENT. A Southwell representative will call you to schedule your appointment as soon as possible.

Contact information of person RECEIVING the vaccine:

Name*

Address*

City/Town*

State/Province*

Zip/Postal Code*

Phone Number*

Date of birth of person RECEIVING the vaccine:*

Phone number of person SCHEDULING the vaccine if different from person receiving the vaccine (i.e., caregiver):

Race of person receiving the vaccine*

Asian

Black/African American

American Indian/Alaska Native

Multicultural

Hawaiian or Polynesian

Unknown

White

Multicultural

Gender*

Male

Female

Ethnicity*

Non-Hispanic

Hispanic

Location Request*

Select or enter value

Primary Care Provider

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