Penobscot Valley Hospital COVID 19 Vaccine Registration

Please complete this form if you would like to sign up to be scheduled for the COVID Vaccine when available.
Phase 1b criteria can be found at:
https://www.maine.gov/covid19/vaccines/phases

If you have questions about the vaccine please contact your provider.










Underlying Medical Condition Criteria for Phase 1b:

The information you choose to disclose will be used to determine your priority in receiving the vaccine. This information will be seen by PVH personnel and will be destroyed upon completion of the vaccination process.:

Category 1:Please disclose any of the following conditions you may have (check all that apply):












Category 2: Please disclose any of the following conditions you may have (check all that apply):