Index - EAMC Secure Forms

COVID-19 Vaccine Registration

This is the East Alabama Medical Center portal for COVID-19 vaccine registration.

At this vaccination site, vaccines are available for persons age 75 and greater who reside in Lee, Chambers or Macon counties.

If you meet the age and residence requirements, please complete the form below with your demographic information and you will be called to schedule your vaccine.

It may take several days to receive a call as vaccine is still very limited.
Once you receive your confirmation that your data has been entered into the registry, there is no need to register again. Any changes can be made when you are called.

The vaccine site is wheelchair accessible. If you are walking, you will need to be able to walk up to 60 feet at a time.

I am unable to meet these mobility requirements.

First Name

Middle Name optional

Current Last Name

Gender

Date of Birth

Ethnicity

Race

Home Address

City

County

State

Email optional

Primary Phone

Primary Phone will be used to schedule appointments

You will need to bring your driver’s license or other form of picture ID to the vaccination site.

I certify that I meet the age and residency requirements.

We understand that your privacy and security are of the utmost importance. For your peace of mind, registration information is encrypted in-transit utilizing industry standard technologies (SSL or TLS, depending on your device support).