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

Click here to register for a covid vaccine booster.

To register to recieve the COVID-19 vaccine please complete the form below. You will be contacted by a member of our staff at the phone number you provided on this form to be scheduled for a vaccine. Please make sure the contact number provided is accurate.

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

Thank you!

This program is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $128,000 with 0% financed with non-governmental sources. The contents are those of Memorial Hospital and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.

All Illinois residents age 5 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. Age 5-11 will only receive Pfizer.
Your Medical Provider's Name *
Please list any chronic health conditions here:

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