REMINDER—this is a preregistration only. Once our office has received vaccine, we will begin scheduling appointments.
Please fill out the top section ONLY (the remainder will be completed at the time of your vaccine). We need all boxes filled out in order to schedule an appointment. If a section does not apply, then put NA.
Once filled out the form can be emailed to, faxed to 660-827-1141, mailed to 911 E 16th Sedalia MO, or dropped off at the clinic from 9am to 4 pm Monday through Thursday.
If your primary care provider is part of the Katy Trail or Bothwell group, we will forward your information to your PCP.
The vaccine is a 2 step, therefore you will be scheduled for your initial dose and second dose at the same location.
NOTE: check with your employer to see if they will be participating in an on-site vaccine clinic.
If you have any questions, call 660-827-1130. We do ask that you be patient as we have limited phone lines and case investigations are still being worked on at this time.

Please click on the Image below to open document.

You must have Adobe Reader for your computer or cell phone to be able to fill out the form. After filling it out, you must download it, save it and attach it to the e-mail given above or you may just print it and mail it to the address given.