Vaccination Sign Up Form
‌(Phase 1A - Qualifying Medical Condition)

Must be a Bucks County resident or employed in the county and one of the following:

  • Persons ages 65 and older
  • Persons ages 16-64 with high-risk conditions:
  •      Cancer
  •      Chronic kidney disease
  •      COPD
  •      Down Syndrome
  •      Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies
  •      Immunocompromised state (weakened immune system) from solid organ transplant or from blood or bone marrow transplant, immune deficiencies, HIV, use of corticosteroids, or use of other immune weakening medicines
  •      Obesity (body mass index [BMI] of 30 kg/m2 or higher)
  •      Pregnancy
  •      Sickle cell disease
  •      Smoking
  •      Type 2 diabetes mellitus

Note that at this time only the Pfizer-BioNTech product is approved for those age 16 and 17.

*These categories are general groups. For a more granular list of eligible positions please consult the DOH vaccine plan found here:
https://www.health.pa.gov/topics/Documents/Programs/Immunizations/
‌PA%20Interim%20Vaccine%20Plan%20V.4.pdf


*Additional vaccine guidance can be found at the Department of Health's website here:
https://www.health.pa.gov/topics/disease/coronavirus/Pages/Vaccine.aspx

Vaccination Sign Up Form for 
‌Qualifying Medical Conditions

**Each Household Member Requires 
‌Separate Submission.