Bureau County Essential Workers & Individuals 65+
This form does NOT confirm a vaccination appointment. Expect to be contacted by the BPMHD at a later date concerning your appointment confirmation.
Please enter a valid phone number.
Secondary Contact (Name & Phone Number)
Town You Reside:
Have you tested positive for COVID-19 in the last 6 weeks?
Underlying Health Conditions:
Once you click the submit button below, you will be directed to a "Thank You" page to confirm that your submission has been received.
Should be Empty: