Development Office

COVID Screening Form

COVID 19 Vaccination Screening Form

We received our second shipment of first vaccine doses. This phase is designed to serve ages 18 to 64 with specific at-risk conditions. Once you complete the REGISTRATION FORM, you need to complete this VACCINATION SCREENING form. Once both forms are complete and a logistics coordinator validates your condition, you are ready for your scheduled vaccination appointment.
If you did not fill out the REGISTRATION FORM, please go to http://www.mcmh.us/forms and click REGISTER to complete the form as a first step in getting the Vaccine. A logistics coordinator will get back to you to conduct the screening process, validate your at-risk condition, and confirm your appointment.

Section 2 - Insurance

Section 3: COVID19 SCREENING

PLEASE CHECK YES OR NO FOR EACH QUESTION

Click YES to give consent, Type your full name, and click SUBMIT to finish.

Section 4: Certification & Authorization Statement

DO NOT WRITE BELOW THIS LINE


Details below are coming soon, please excuse our dust!

Grants

Click for grants (COMING SOON)

Ministerial Alliance

Click for Ministerial Alliance (COMING SOON)

Partnerships

Click for Partnerships (COMING SOON)

Patient Experience

Click for Patient Experience (COMING SOON)

Provider Relations

Click for Provider Relations (COMING SOON)

Public Relations

Click for Public Relations (COMING SOON)

Research & Development

Click for Research & Development (COMING SOON)

Partnerships

Click for Volunteering (COMING SOON)

Wellness

Click for Wellness (COMING SOON)

Media Relations

Click for media relations (COMING SOON)

  • Stephanie Johns
    Stephanie Johns

    Wellness Ambassador
    Contact: 
    850.253.1961

  • Lori Evans
    Lori Evans

    Foundation & Public Relations Director
    Contact: 
    850.253.1971

  • Karen Kocan
    Karen Kocan

    Business Development
    Contact:  850.253.1961

Contact Us

We're not around right now. But you can send us an email and we'll get back to you, asap. You can also send us a message through our Facebook page. Please do not include personal health information in your communications through social media.

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