COVID Vaccination Request Form

Pole Mountain Pharmacy is prepared to receive vaccine and is excited to begin vaccinations as soon as possible. It is not yet known when that will be and which groups will be eligible at that time. If you would like to be notified when vaccine is available please complete this form. Please note that completing this form does not guarantee that you will receive vaccine. The team from Pole Mountain Pharmacy will contact you via email or phone to notify you when you are eligible to book your vaccine appointment as the vaccine becomes available. If you are filling out this form for additional family members over 18 years of age, please fill out ONE FORM PER PERSON. The vaccines will be provided at no cost to the patient.
  • Please visit the Wyoming Department of Health for the latest information on vaccine phases and distribution https://health.wyo.gov/publichealth/immunization/wyoming-covid-19-vaccine-information/
Font Resize