Covid vaccine appointment forms

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COVID-19 Vaccination Patient Form

If you have scheduled a vaccination appointment with PHC, you will need to fill out the form below.  We will have copies available on site, but our process is made much easier if you are able to have this filled out when you arrive.  

Pre-Appointment Form (click here)
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Other Important Documents 

 There are two more important informational documents for vaccine recipients. These do not need to be printed and you do not need them to get vaccinated.  You will be offered hard copies of these documents at your vaccination appointment, but we encourage you to download electronic versions and decline a hard copy in order to save paper.

Document #1: V-Safe   
Free, Smartphone-Based Tool that uses text messaging and web surveys to provide personalized health check-ins after you receive a COVID-19 vaccination. 

Document #2:  Vaccine Info Sheet  
Fact sheet with important information about COVID-19 vaccines (select the link for the specific vaccine you received or are scheduled to receive)
- Pfizer-BioNTech
- Moderna
- Johnson & Johnson / Janssen
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Logo of Partnership Health Center-- Missoula's Community Health Center
401 Railroad St. W 
Missoula, MT 59802

​Main Line: (406) 258-4789
​
Dental: (406) 258-4185
Behavioral Health: (406) 258-4789
Pharmacy: (406) 258-4139
Billing: (406) 258-4195
Fax: (406) 258-4732

View hours at all our locations here.

Contact PHC


Find Us

We are conveniently located in downtown Missoula at 401 Railroad St. W. We are easily accessed from I-90 via the Orange Street Exit. PHC is also just blocks away from the Mountain Line Transfer Station, also located downtown.
This health center receives HHS funding and has Federal Public Health Service (PHS) deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.
 NOTICE OF NONDISCRIMINATION: 
Partnership Health Center does not discriminate against any person on the basis of race, color, national origin, disability, age, or sex (gender) in admission, or access to, or treatment, or employment in, its programs, services, or activities.  
Read the Full Notice:  Partnership Health Center Notice of Nondiscrimination
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LIMITED ENGLISH PROFICIENCY ASSISTANCE: 
Partnership Health Center
provides language assistance services, including translated documents and oral interpretation, to individuals with limited English proficiency. We provide assistance in the following languages:
Español  |  Tiếng Việt  |  繁體中文  |  한국어  |  Русский  |  العربية  |  Deutsch  |  Français  |  Tagalog  | ภาษาไทย  |  Norsk  |  Українська  |  Deitsch  |  Italiano  |  日本語 

Partnership Health Center respectfully acknowledges that we occupy the traditional homelands of the Séliš, Qĺispé, and Ktunaxa-Ksanka nations. We also recognize that these lands are a site of trade, medicine gathering, healing, and travel for other Native tribes in the area and is still home for many Indigenous people. We extend our gratitude for those who have stewarded this land since time immemorial.
 
We acknowledge that the health care system has played a role in the oppression of Indigenous peoples. We commit to ongoing learning about the impact of colonization on the health and wellbeing of Indigenous peoples, and we commit to meaningful action that reverses health inequities.

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  • Services
    • Medical
    • Dental
    • Behavioral Health >
      • Self-Care Resources
    • Pharmacy
    • Telehealth
    • Additional Services >
      • Medicare Wellness Visit
      • Montana Cancer Screening Program
      • Medical Legal Partnership
      • Certified Application Counselors
      • Sports Physicals
  • Patients
    • Appointments >
      • Online Scheduling
    • Forms
    • Financial Assistance >
      • Sliding Fee Scale
      • Good Faith Estimate
    • Patient Web Portal
    • Pay My Bill
  • About
    • Welcome
    • History
    • Who We Are
    • Our Providers
    • Locations & Hours
    • Education and Training
    • Donate
  • News & Events
    • Public Meetings
    • Events and Announcements
    • PHC in the News
    • COVID-19 Updates
  • Careers
  • Contact Us
    • Provide Feedback