LCTHC Vaccine Clinic Sign-up Form

Please submit the information below to be placed on the LCTHC vaccine call list.

Name Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Phone Number Phone Number - ### - ### ####
Are you a current LCTHC patient?

Are you a current LCTHC patient? Yes No
Are you American Indian or Alaska Native?

Are you American Indian or Alaska Native? Yes No