If you are an individual who is homebound due to physical restrictions, medical conditions, or other chronic physical or mental health 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.
For frequently asked questions, please visit: COVID-19 Vaccinations-FAQs (ct.gov).
Information of Intake form submitter on behalf of Homebound Person