UnityPoint Health - Memorial Hospital Sign up for the COVID-19 Vaccine Hancock County, IL COVID-19 Info
COVID-19 Vaccine Sign-up

Coronavirus Vaccine Signup

Thank you for registering for our waiting list to receive the COVID-19 vaccine. 

Please do not call the hospital or any of our clinics to confirm or see where you are on the list.  

  • You will be contacted by a member of our staff at the phone number you provided on this form when you have been scheduled for an upcoming vaccine clinic.  Please make sure the contact number provided is accurate.

We cannot guarantee vaccination by being put on this list.  If you have another opportunity to receive the vaccination, we suggest you take advantage of that opportunity.

We ask for your patience and understanding as we work hard to vaccinate our community. Thank you!

All Illinois residents age 18 and older are currently being served.

Required fields are marked with an asterisk *

First Name *
Last Name *
Phone *
Email *
Address 1 *
Address 2
City *
State *
Zip Code *
Date of Birth (mm/dd/yyyy) *
Please select your vaccine preference. Please note we will NOT offer Johnson & Johnson vaccines to females age 35-55.
Your Medical Provider's Name *
Please list any chronic health conditions here:

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