ATTN: ALL Kentucky Citizens who are 16 years or older

You are now eligible to pre-register for the COVID-19 vaccine. Once registered, it will be very important that you read the IMPORTANT INFORMATION on the "Thank You" page and answer the phone when we call (Caller ID will register with a 606-43x-xxxx number). Vaccines will be administered on the PMC campus. Please note! Those 16 and 17 years old must have a parent present to sign a consent form.

Please fill out the secure form below.

First Name: *
Last Name: *
Date of Birth: * Month:

Day:

Year:
Phone: *
County where you reside: *
Example: Pike, Floyd, Johnson, etc...
I certify that I am a Kentucky resident: * Yes, I certify