This form is currently ONLY for homebound Contra Costa County residents that meet eligibility criteria to request a vaccination appointment through Contra Costa Health Services’ Mobile Vaccine Team.

Contra Costa Health Services (CCHS) recognizes that not all county residents have the physical ability to leave their homes to get vaccinated at one of our clinics. Homebound residents or their caregivers can fill out this form to request to have the CCHS Mobile Vaccine Team go to their homes.

If you are submitting this form on behalf of someone else, please confirm that the patient/resident consents to vaccination prior to making the request.   

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