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2. Vaccination Appointment Cancellation Request

   This form is to request cancellation of a vaccination appointment that has been scheduled at either of the PORTER COUNTY HEALTH DEPARTMENT Vaccination Locations ONLY!

4. All fields in this form REQUIRE an answer. Please be sure to verify that you have answered all questions before you submit this form. You will not be able to submit this form unless all questions are answered.
6. Are you cancelling the appointment for yourself or for someone else?*

   1. Myself

   1. Someone Else
8. What is your relationship to the person for whom you are cancelling this appointment?*
10. What Is Your First Name?*
11. What Is Your Last Name?*
13. What Is Your Email Address?*
14. What Is Your Daytime Phone Number?*
16. Appointment Information
18. Enter The First Name Of The Person The Appointment Is For:*
19. Enter The Last Name Of The Person The Appointment Is For:*
21. Enter The Email Address Of The Person The Appointment Is For:*
22. Enter The Daytime Phone Number Of The Person The Appointment Is For:*
24. Enter The Date Of Birth Of The Person The Appointment Is For:*
    Please enter in MM/DD/YY format
25. Enter The Date & Time Of The Appointment You Are Cancelling:*
    Enter The Date & Time Of The Appointment You Are Cancelling:

    Enter The Date & Time Of The Appointment You Are Cancelling:
27. At Which Porter County Health Department Location Is The Appointment Scheduled For?*

    1. Health Department Office In Valparaiso

    1. Health Department Office In Portage
29. You are almost done. Just click on Submit below and you will be directed to a submission confirmation page. If you are NOT redirected, it usually means that you have not answered all questions. Please scroll up and answer any highlighted questions then click on Submit or Submit & Print again.
Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

* indicates a required field