This form will provide the University of Maryland Health System with the information needed to determine your vaccination prioritization using guidance from the Maryland Department of Health's COVID-19 Vaccination Plan.
Completing the form DOES NOT create an appointment. Once it is your turn and an appointment is available, you will receive an email or phone call with further information about how to schedule an appointment. Due to a high volume of requests, wait times between submitting a request form and receiving an invitation to schedule could be significant.
If you are unable to complete this form online, please ask a healthcare provider, friend, neighbor, or family member for assistance.
BEFORE YOU GET THE VACCINE, you MUST talk to your doctor as needed for guidance related to individual medical conditions (e.g., history of allergic reaction, bleeding disorders, immunocompromised individuals, etc.). If you have a history of severe allergic reaction to another vaccine or injectable therapy, you WILL NOT be able to get the COVID-19 vaccine unless you have gotten approval from your doctor PRIOR TO your appointment.
Please do NOT resubmit this form with a duplicate request as this will cause confusion for the scheduling team and will result in further delays.
There is a limited supply of vaccine nationwide. Please be patient as we work to provide our patients with an opportunity to make a vaccine appointment.