Vaccine Appointment

**Please fill out using Google Chrome, Microsoft Edge or Firefox. Internet Explorer is not supported**

• Remember to bring your vaccination card, photo ID, and insurance information with you.
• You are required to wait a minimum of 15 minutes after receiving the vaccine for observation. 
• Masks are optional and not required for visitors or patients. Masks are available if needed.  
• If you are not able to make it to your appointment or you are sick on the day of your appointment, please call Mobridge Regional Hospital & Clinics at 605-845-3692 to cancel your appointment.

Appointment Date*		Please Select2023-10-26
Appointment Time*		Please Select
First Name*
Last Name*
Date of Birth*
Is this a booster or 3rd dose?*		Yes No
City*
County*
Phone Number*
Email