Stay informed, help us prepare

Sign up by clicking the image above to let us know you're interested in getting a vaccine. We’ll send you updates on how we’re providing vaccines across the country — and when you can get your vaccine if you want one. We’ll also offer information and answers to your questions along the way. Also, by filling out all the information fields, it lets us know here at the WNC VA Health Care System that you are interested in getting the vaccine. There is no need to do anything else. Our health care professionals will contact you to set up an appointment.

(When you sign in, the website can fill in some of your information for you.)

• You don’t need to sign up to get a vaccine. And, you can change your mind about getting a vaccine at any time. We’ll use the information you provide to understand your interest and keep you informed.

Filling out the form

The KMI form has nine questions. If a user is signed in, this information is often pre-filled, but the user can edit his or her answers if they want to. If the user isn't signed in, they will need to enter the required information. The form asks for the following information:

• First name (required)

• Last name (required)

• Date of birth (optional, but highly useful for matching patient records)

• Social Security Number (optional, but highly useful for matching patient records)

• Email address (required) • Phone (required)

• Zip code (required)

• Question 1: Will you be in this zip code for the next 6-12 months? (required)

• Question 2: Do you plan to get a COVID-19 vaccine when one is available to you? (required)

** Please visit VA.gov to see what the form looks like.

KMI Questions or Concerns

I am trying to sign in to fill out the form but it is not working.

If you are having trouble signing in when attempting to complete the KMI form, please use the “Continue without signing in” button and provide your SSN and DOB on the form.

If I complete this form, am I signing up to get the COVID-19 vaccine?

We’ll use the information you provide to understand your interest and keep you informed by email. You don’t need to sign up to get a vaccine, and you can change your mind about getting a vaccine at any time.

Why are you asking for my date of birth and Social Security Number?

It is not required to provide your date of birth or social security number when filling out this form. However, providing this information will help the VA match your information to your Veteran records so we can better understand your needs as we keep you informed on the VA’s COVID-19 vaccine distribution plan.

What can I expect to happen after I fill out this form?

When the VA has new information to share about its COVID-19 plans and your vaccine options, you will receive an update by email or text. You can also visit our main COVID-19 vaccines at VA page for the latest information and answers to common questions: https://www.va.gov/health-care/covid-19-vaccine/.

Remember: This form doesn’t sign you up to get a vaccine. The VA will use the information you provided to understand your interest and keep you informed. You can change your mind about getting a vaccine at any time. If you want to update your information later, you can submit a new form.