Vaccine Interest 1A - Jefferson County General Health District

500 Market Street
6th Floor
Steubenville, OH 43952

Vaccine Interest Form - Phase 1A

Which category do you work in or does your company fall under? *

Company/Agency Name *

Primary Contact Name *

Street Address *

City *

State *

Zip *

Primary Contact Phone Number *

Primary Contact Email *

Total Number of Staff to be Vaccinated *

Total Number of Residents to be Vaccinated

Time

If you are human, leave this field blank.

Hours of Operation

Sunday: CLOSED
Monday: 8 am – 4 pm

Tuesday: 8 am – 4 pm
Wednesday: 10 am – 5:00 pm
Thursday: 8 am – 4 pm
Friday: 8 am – 3 pm
Saturday: CLOSED

Toronto Office

Monday: 9am – 3pm

We accept payments by cash, credit cards, or check.

There is a $2.50 convenience
fee for credit card payments.