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Thank you for your interest in receiving the COVID-19 Vaccine at D.W. McMillan Memorial Hospital.
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By completing the following form, your information will be submitted to the DWM Vaccine Coordinator. Once the vaccine is available and your phase category has been approved, you will be contacted to schedule an appointment.
Please complete the following information to be put on a waiting list for Phase 1A, 1B & 1C or Phase 2 distribution of the COVID-19 vaccine. Please check the appropriate category below. |
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Must fill in all the following items |
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Full Name |
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DOB |
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Age |
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Address |
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City |
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State |
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County |
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Phone Number |
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Zip Code |
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Per the Alabama Department of Public Health, to qualify for Phase 1A you must be: |
EMT/EMS
Pharmacy or Dentist
Healthcare Worker or Mental Health Provider
Mortician
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Per the Alabama Department of Public Health, to qualify for Phase 1B you must be: |
75 years of age or older
Firefighter/Police or Corrections Officer
Food/Agriculture or Manufacturing
Congregate Living
US Postal
Grocery Store
Public Transit
Education or Child Care
Clergy/Ministers
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Per the Alabama Department of Public Health, to qualify for Phase 1C you must be: |
65 Years - 74 Years Old
16-64 Years old with High RISK Medical Condition (Moderna & Johnson/Johnson Vaccine requires 18+)
Transportation or Logistics
Waste and Wastewater
Food Service/Shelter or Housing
Finance/Information Technology or Communication
Energy/Media/Legal or Public Safety
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Per the Alabama Department of Public Health, to qualify for Phase 2 you must be: |
All persons in age groups not previously recommended for vaccine ages 16-64 (Moderna & Johnson/Johnson Vaccine requires 18+)
General Population not included in earlier phases
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