REQUIRED fields (noted with an *)

First Name: *

Last Name: *

Date Of Birth: *
Month: *

Day: *

Year: *



Contact info: (please provide one or both) *
Email:
Phone (10 Digit):

This information will only be used to reach out to you if we have a question about your vaccination.


Address:

Street: *

City: *

State: *

Zip: *


Upload an image
of the front of
your vaccine card
(JPG only) *




* I affirm that the information provided is accurate to the best of my knowledge. Additionally, I grant permission to the Sullivan County Department of Public Health to enter the COVID19 vaccination information reported above into the New York State Immunization System (NYIIS).