Homebound Intake form

Homebound Intake Form

* - Required Field

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If you are an individual who is homebound due to physical restrictions, medical conditions, or other chronic conditions, and therefore cannot attend a community clinic, please fill out this form. If you fill out this form, a person in your town will contact you. We will only share your information with that person. That person will help you get a COVID-19 shot. Please be patient, information is shared with towns once a week on Mondays. You do not have to fill out this form if you have another way to get the COVID-19 shot.

If you only need a ride to get a COVID-19 shot, you should not complete this form. You should click on this Transportation Resources link for help finding a ride.

For frequently asked questions, please visit: COVID-19 Vaccinations-FAQs (ct.gov).

Are you submitting the form on behalf of the homebound person?

Yes No *

Enter the contact person first name for follow-up and scheduling for the homebound person*

Enter the contact person last name for follow-up and scheduling for the homebound person*

Enter the contact person email for follow-up and scheduling for the homebound person*

Enter the contact person phone number for follow-up and scheduling for the homebound person*

Information of Homebound Person

Are you an individual who is homebound due to physical restrictions, medical conditions, or other chronic conditions, and therefore cannot attend a community clinic to get COVID-19 vaccinated?

Yes No *

Do you have a history of anaphylaxis or severe allergic reaction requiring the use of an epinephrine auto-injector (eg. EPI pen)?

Yes No *

First Name of the Homebound Person*

Last Name of the Homebound Person*

Email of the Homebound Person

Phone Number of the Homebound Person*

Date Of Birth*

Home Address of the Homebound Person*

Apartment/Unit Number

City/Town*

State*

Zip Code*

Has the homebound person already received a COVID-19 vaccine?

Yes No *

DEPARTMENT OF PUBLIC HEALTH

DPH Submissions System