Broward Health is offering a limited number of COVID-19 vaccination appointments to immediate family members of Broward Health employees and credentialed medical staff who are considered to be at high-risk of developing complications from COVID-19.

Many employees and medical staff have expressed interest in vaccinations for their at-risk family members and loved ones who were not eligible in the first tier. It’s our honor and privilege to help protect your loved ones who are most vulnerable to the effects of COVID-19.

Your immediate family members are defined as: spouse, domestic partner, adult son, adult daughter, mother, father, mother-in-law, or father in-law. Or, a relative that lives in your household.

Please complete the consent and attestation as outlined below. Appointments are required. Walk-ins will not be accepted at the vaccination site.


For more information on the COVID-19 vaccine, please download the EAU Fact Sheet.


Date must be entered as MM-DD-YYYY
please enter as xxx-xxx-xxxx
please enter as xxx-xxx-xxxx
please enter as xxx-xxx-xxxx
Screening Questions (if you answer yes, please explain below)
Notes
I hereby acknowledge the following: